Customer's Claim & Affidavit
Damage to customer's property is included under a commercial general liability policy; this form describes items lost, seller, purchase date and depreciation. The claim amount is submitted with signature of customer and adjuster.
PDF (59KB)
Liability
Property
Forms Property & Casualty
Non-Waiver Agreement / Reservation Of Rights
The non-waiver agreement is signed by the policyholder; its purpose is to protect the insurer. Insurer reserves all of its rights under the policy to investigate and defend a claim without admission of any liability for loss.
PDF (36KB)
Auto
Liability
Property
Workers' Compensation
Forms Property & Casualty
Inquiry Form - Index System
This inquiry form requests claim details for a third party using an Index System.
PDF (16KB)
Liability
Forms Property & Casualty
Car Evaluation Analysis
Appraisal form used to determine a vehicle's value after a total loss by considering the book value and local market value (dealer quotes). Add or deduct value using a comparable vehicle model, noting trim, paint, glass, tires, power options, mechanical condition and cleanliness.
PDF (126KB)
Auto
Forms Property & Casualty
Hold Harmless Agreement
This is a contract that releases one party from any legal and financial responsibility for all loss or damage or future claims by the other party in exchange for a settlement.
PDF (20KB)
Liability
Property
Forms Property & Casualty
Claim Register Sheet
Basic registry form for logging when claims are received and closed.
PDF (83KB)
Auto
Liability
Property
Workers' Compensation
Forms Property & Casualty
Adjuster's File Invoice
An invoice form used by independent adjusting firms that lists claims investigation expenses billable to the client insurance company.
PDF (48KB)
Auto
Liability
Property
Workers' Compensation
Forms Property & Casualty
Complete Release Of All Claims (Spanish)
A full release and indemnity agreement which is signed by claimants and releases insurer from bodily injury and property damage liability which arose out of an accident, casualty or event. The release form identifies all parties to a claim, states the date and location of the event, and details the terms of settlement of a claim. The release contains a statement that, as a condition of the settlement, prevents any further claim or legal action against the insurer, or any other parties, for the event, and against the release.
PDF (95KB)
Liability
Spanish
Forms Property & Casualty
Vehicle Inspection Report
Auto Examiner or Adjuster's vehicle inspection report form.
PDF (22KB)
Auto
Forms Property & Casualty
Notice Of Loss Burglary-Robbery-Theft
A loss report form filled out by an insured when reporting a theft claim to an insurance company. Includes circumstances of the theft, and a list of items claimed as stolen with declared values.
PDF (47KB)
Property
Forms Property & Casualty
Receipt & Release Medical Payments Coverage
This form is signed by those who qualify as insureds under a policy when collecting medical payments coverage. Used as both a receipt and a release.
PDF (21KB)
Liability
Forms Property & Casualty
