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Name
POLICY INFORMATION
WHAT IS YOUR RELATIONSHIP TO ONESOURCE CMS?
*
Insured
Claimant
Agent
Attorney
Other
POLICY NUMBER
*
DATE OF LOSS
*
TIME OF LOSS
*
INSURED INFORMATION
YOUR ROLE
*
Insured Owner
Other Party
Renter
Mortgagee
Lessor
Lessee
Other
BUSINESS NAME OR INDIVIDUAL
Business
Individual
CONTACT INFO
PHYSICAL ADDRESS
*
CITY
*
ZIP CODE
*
STATE
*
COUNTRY
HOME
*
WORK EXT
MOBILE
*
EMAIL
OTHER
ADDRESS OF OCCURRENCE
PHYSICAL ADDRESS
*
CITY
*
ZIP CODE
COUNTRY
HOME
*
WORK EXT
MOBILE
EMAIL
OTHER
LOSS INFORMATION
TYPE OF LOSS
All Risk
Bodily Injury
General Liability
Garage Keepers
Personal Liability
Business Owners
Business Interruption
Equipment Breakdown
Hospitality
BPP
Inland Marine
Crime
Named Peril
Death
Slip and Fall
Personal Property
Other
LOSS DESCRIPTION
*
CLAIMANT INFORMATION
FIRST NAME
*
LAST NAME
*
PHYSICAL ADDRESS
*
CITY
*
ZIP CODE
*
STATE
*
COUNTRY
HOME
*
WORK EXT
MOBILE
EMAIL
OTHER
WITNESS INFORMATION
IS THERE A WITNESS
Yes
No
