Reservation Of Rights Agreement
A reservation of insurer's rights to discovery, settlement, or defense in denial of a claim for loss and damages, agreed to by insured.
PDF (19KB)
Auto
Liability
Property
Special Investigations
Workers' Compensation
Forms Property & Casualty
Automobile Accident Report - NY
Report form, customized for New York, that is given to vehicle owners and drivers to capture the details of an accident. Includes occupants, injuries, property damages, crash diagram, driver's account of accident, and witnesses.
PDF (71KB)
Auto
Liability
Forms Property & Casualty
Notice Under Subrogation Rights (Spanish)
Claim form used to notify an individual of subrogation rights of an insurer for an auto insurance loss.
PDF (31KB)
Auto
Liability
Spanish
Subrogation
Forms Property & Casualty
Drivers Statement (Spanish)
A driver's written statement of sequence of events and collision information.
PDF (71KB)
Auto
Liability
Spanish
Forms Property & Casualty
Guidelines and Requested Data for Electrical Systems at Fire Scenes
A guide for fire scene investigation of electrical systems.
PDF (21KB)
Property
Technology
Forms Property & Casualty
Adjuster's Loss Certification and Apportionment of Claim
This form is used to recommend to the insurer the amount of payment for a loss, and apportionment when a property is covered by two or more insurance companies.
PDF (21KB)
Liability
Property
Forms Property & Casualty
Release & Trust Agreement (UM/UIM BI) (Spanish)
A release form signed by an insured when making an uninsured motorist or underinsured motorist claim. Requires the insured to cooperate in the recovery of funds from the responsible party.
PDF (65KB)
Auto
Liability
Spanish
Subrogation
Forms Property & Casualty
Proof Of Loss Medical Payment (Spanish)
A declaration by an insured person that itemizes payments made for medical services after an accident which qualify for medical expense coverage under the policy.
PDF (34KB)
Liability
Spanish
Forms Property & Casualty
Medical Authorization (HIPAA Compliant) (Spanish)
Authorization form for disclosure of medical records, in compliance with HIPAA requirements.
PDF (76KB)
Liability
Spanish
Workers' Compensation
Forms Property & Casualty
Affidavit Of Vehicle Theft (Spanish)
This legal form must be filled out by the insured and notarized. Includes information on vehicle ownership, description & condition, financing, as well as details regarding the theft and police report.
PDF (85KB)
Auto
Spanish
Forms Property & Casualty
Release And Trust Agreement (UM/UIM PD)
A release form signed by an insured when making an uninsured motorist or underinsured motorist claim involving property damage.
PDF (24KB)
Auto
Liability
Subrogation
Forms Property & Casualty
Automobile Accident Promissory Note (Spanish)
Customized automobile subrogation promissory note which allows the insurance company to notify DMV/BMV in case of default by the tortfeasor.
PDF (56KB)
Auto
Liability
Spanish
Subrogation
Forms Property & Casualty
Pennsylvania WC Forms
A collection of workers' compensation forms which are authorized to be used in the state of Pennsylvania.
PDF (0KB)
Workers' Compensation
Forms Property & Casualty
Notice Of Loss - Inland Marine
The inland marine notice of loss form describes the circumstances and amount of loss, and is prepared by an adjuster and presented to the insurer.
PDF (25KB)
Property
Forms Property & Casualty
