Claim Register Sheet
Basic registry form for logging when claims are received and closed.
PDF (83KB)
Auto
Liability
Property
Workers' Compensation
Forms Property & Casualty
Release With Medical Agreement
This is a contract that releases an insurer from any legal and financial responsibility for injury and liability claims after a specified time period and medical expense settlement amount is agreed upon.
PDF (28KB)
Liability
Forms Property & Casualty
Statement As To Replacement Cost Coverage
A legal form stating the values used to calculate cost coverage for repair or replacement of a property loss.
PDF (26KB)
Property
Forms Property & Casualty
Statement Of Loss With Enclosures
An adjuster's statement of a loss using Schedules A, B & C, that includes enclosures.
PDF (61KB)
Property
Forms Property & Casualty
Automobile Proof Of Loss
A policyholder must provide this sworn statement in support of an automobile claim. The notarized form documents the date and cause of loss, vehicle identification, settlement amount, and reserves subrogation and other rights of the insurer.
PDF (46KB)
Auto
Liability
Forms Property & Casualty
Subrogation Receipt
A subrogation receipt is signed by the insured upon payment of a claim, and assigns the insurer to the right to recovery for the loss.
PDF (27KB)
Auto
Liability
Ocean Marine
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
Adjusters Report/Certification
The Adjusters Report/Certification documents the insured property's location, date and type of loss, and summarizes replacement cost and A.C.V. for buildings, structural, contents and additional living expense, with line item detail.
PDF (47KB)
Property
Forms Property & Casualty
PIP Wage & Salary Verification
This form is used to verify wage and salary information of a person who has applied for personl injury protection (PIP) benefits after an automobile accident.
PDF (33KB)
Liability
Forms Property & Casualty
Property Loss Worksheet (Spanish)
Use this worksheet to inventory property and content losses, and obtain an estimate of replacement costs. It contains columns to factor in age, original cost, replacement cost and depreciation to calculate ACV (actual cash value).
PDF (91KB)
Property
Forms Property & Casualty
Attending Physician's Report
A physician treating a person seeking medical benefits under an automobile insurance policy must complete this report.
PDF (55KB)
Liability
Workers' Compensation
Forms Property & Casualty
