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| Accident/Incident Date & Time: | |
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| Church/Organization Name: | |
| UCCIB Church ID Number (if you know it): | |
| Street Address: | |
| P.O. Box: | |
| City: | |
| State: | |
| Zip: | |
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| Address Of Where Loss Occurred? |
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| Contact Person(s): | |
| Title: | |
| Daytime Phone: | |
| Evening Phone: | |
| Fax: | |
| E-mail: | |
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| What Type Of Loss Are You Reporting? |
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| Auto and workers' compensation claims should be called into the carrier directly. Please read the instructions on the IB claims webpage - here.) |
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General Description of damages, injury, and how it happened:
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| Claimant Name: |
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Claimant Full Address:
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| Claimant Phone: |
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| Has An Estimate Been Completed? |
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| If Yes, Please Provide The Amount: |
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Do you have any additional documentation to provide the adjuster? If yes, please state.
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Has a police report been completed? If yes, please provide the date of reporting, police report number, and name of police department that completed the report.
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Is this a hired or non-owned vehicle claim? Please provide the vehicle VIN number, information on the owner of the vehicle, and contact information for the owner of the vehicle.
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Is it possible that you or anybody else previously reported this claim? If yes, please provide details such as claim number:
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