General Liability Notice Of Occurrence Form

Last Report Generated (click to view or download)
 Employer Name
 Location Name
 Department Name
 FROL ID
 Hidden Record ?
 Record Marked for Delete ?

        Basic Case Information
 Report Number
 Date Prepared
 Date Of Loss
 Time Of Loss
 For Information Only
 Claim Status
 Carrier Claim Number
 First Incident Identifier
 Second Incident Identifier

        Agency Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Contact
 Contact Phone
 Fax
 Contact Email
 Agency Code
 Agency Subcode
 Customer ID
 Insured Location Code
 Carrier Name
 Carrier NAICS
 Policy Number

        Insured Information
 Name
 Date of Birth
 FEIN
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email

        Contact Information
 Contact Insured
 Name
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 When To Contact
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email

        Occurrence Information
 Address
 City
 State
 Zip
 Country
 Police or Fire Department Contacted
 Police or Fire Department Report Number
Description of Occurrence (150 characters max)

        Type Of Liability Information
Premises / Owner Information
 Insured Is Owner
 Insured Is Tenant
 Insured Is Other
 Insured Is Other Description
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Type Of Premises
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
Product / Manufacturer Information
 Insured Is Manufacturer
 Insured Is Vendor
 Insured Is Other
 Insured Is Other Description
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Type Of Product
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
 Can Be Seen Where

        Injured / Property Damaged Information
Injured / Owner Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
Employer Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
Injury Information
 Injured Age
 Injured Gender
 Injured Occupation
Describe Injury (75 characters max)
Injured Taken Where (75 characters max)
What Was Injured Doing (75 characters max)
Property Damaged Information
 Describe Property
 Estimate Amount
 Can Be Seen Where

        Witness Information
First Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
Second Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email
Third Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Primary Email
 Secondary Email

        Remarks
Remarks (750 characters max)
 Reported By
 Reported To

        Additional Remarks - Sheet 1
Additional Remarks Sheet 1 (Acord 101 Form - 3500 characters max)

        Additional Remarks - Sheet 2
Additional Remarks Sheet 2 (Acord 101 Form - 3500 characters max)

        Identification Code
 Code Description
 Code Value

        User Defined Fields
 User Defined Text 1
 Total Med Cost in $
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

        Report History
Report History (click to view or download)


 Release Status
 Release Date
 Release Actions
Release Comments (300 characters max)