Web Submitted Claim


{{vm.data.formName}} Claim

Incident ID: {{vm.data.incidentId}}

Claim Number: {{vm.data.claimnumber}}


Zurich Insured

Insured Name
{{vm.data.zurichInsured.insuredName}}
Parent Company
{{vm.data.zurichInsured.parentCompanyName}}
Policy Number
{{vm.data.zurichInsured.policyNumber}}
Site Code
{{vm.data.zurichInsured.siteCode}}
Phone Number
{{vm.data.zurichInsured.phone}}
Extension
{{vm.data.zurichInsured.ext}}
Address

{{vm.data.zurichInsured.address.street}}
{{getAddress(vm.data.zurichInsured.address)}}


Reported By

Reporter Name
{{vm.data.reportedBy.contact.name}}
Phone Number
{{vm.data.reportedBy.contact.phone}}
Extension
{{vm.data.reportedBy.contact.ext}}
Email
{{vm.data.reportedBy.contact.email}}
Relationship to Claim
{{vm.data.reportedBy.relationshipValue}}
{{vm.data.reportedBy.otherRelationship}}

Insured Contact

Contact Name
{{vm.data.insuredContact.contact.name}}
Phone Number
{{vm.data.insuredContact.contact.phone}}
Extension
{{vm.data.insuredContact.contact.ext}}
Cell Phone
{{vm.data.insuredContact.cellPhone}}
Fax
{{vm.data.insuredContact.fax}}
Email
{{vm.data.insuredContact.contact.email}}

Accident

Incident Report Only
{{vm.data.accident.incidentReportOnly}}
Loss Date
{{vm.data.accident.lossDate}}
Loss Time
{{vm.data.accident.lossTime}}
Address

{{vm.data.accident.lossLocation.street}}
{{getAddress(vm.data.accident.lossLocation)}}

County
{{vm.data.accident.lossLocation.county}}
Accident Description
{{vm.data.accident.accidentDescription}}
Injured on Insured Premise
{{vm.data.accident.injuredOnInsuredPremises}}
Benefit State
{{vm.data.accident.benefitStateValue}}
Coverage Type
{{vm.data.accident.coverageTypeValue}}
Authority Contacted

{{item.type}} Department
{{item.name}}
{{item.reportNumber}}


Employee

Last Name
{{vm.data.employee.lastName}}
First Name
{{vm.data.employee.firstName}}
Middle Initial
{{vm.data.employee.middleInitial}}
Phone (Home)
{{vm.data.employee.homePhone}}
Phone (Cell)
{{vm.data.employee.cellPhone}}
Email
{{vm.data.employee.email}}

Address

{{vm.data.employee.address.street}}
{{getAddress(vm.data.employee.address)}}

Date of Birth
{{vm.data.employee.dateOfBirth}}
SSN
*****

Marital Status
{{vm.data.employee.maritalStatusValue}}

Dependent Count
{{vm.data.employee.dependentCount}}

Gender
{{vm.data.employee.genderValue}}

Employment

Employer Information
Employer Same as Insured
{{vm.data.employment.employerSameAsInsured}}

Company Name
{{vm.data.employment.companyName}}
Phone Number
{{vm.data.employment.phone}}
Extension
{{vm.data.employment.ext}}
Address

{{vm.data.employment.address.street}}
{{getAddress(vm.data.employment.address)}}

FEIN
{{vm.data.employment.fein}}
Unemployment Number
{{vm.data.employment.unemploymentInsuranceNumber}}
Employer Notified Date
{{vm.data.employment.employerNotifiedDate}}
Employee Information
Employee Id
{{vm.data.employment.employeeId}}
Department
{{vm.data.employment.department}}
Employment Status
{{vm.data.employment.employmentStatusValue}}
Hire date
{{vm.data.employment.hireDate}}
Regular Occupation
{{vm.data.employment.regularOccupation}}
Injury Occupation
{{vm.data.employment.injuryOccupation}}
Hours Worked per day
{{vm.data.employment.hoursWorkedPerDay}}
Days Worked per week
{{vm.data.employment.daysWorkedPerWeek}}
Weekly Wages
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Supervisor Name
{{vm.data.employment.supervisorName}}
Supervisor Phone
{{vm.data.employment.supervisorPhone}}
Loss of Work
Employee Losing Time from work
{{vm.data.employment.employeeLosingTimeFromWork}}
Last Date Worked
{{vm.data.employment.lastDateWorked}}
Disability Date
{{vm.data.employment.disabilityDate}}
Pay Thru Day
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Has Employee Returned to Work
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Date Returned To Work?
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Return To Work with Restrictions
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Injury

Injury Description
{{vm.data.injury.description}}
Injury Resulted into Death?
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Date of Death
{{vm.data.injury.dateOfDeath}}
Cause of Injury
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Initial Treatment
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Hospital/Clinic
Name
{{vm.data.injury.initialTreatment.hospital.name}}
Phone
{{vm.data.injury.initialTreatment.hospital.phone}}
Extension
{{vm.data.injury.initialTreatment.hospital.ext}}
Address

{{vm.data.injury.initialTreatment.hospital.address.street}}
{{getAddress(vm.data.injury.initialTreatment.hospital.address)}}


Accident

Incident Report Only
{{vm.data.accident.incidentReportOnly}}
Auto Dealer Claim
{{getAutoDealerDesc(vm.data.accident.AutoDealerClaim)}}
Loss Date
{{vm.data.accident.lossDate}}
Loss Time
{{vm.data.accident.lossTime}}
Address

{{vm.data.accident.lossLocation.street}}
{{getAddress(vm.data.accident.lossLocation)}}

Accident Description
{{vm.data.accident.accidentDescription}}
Authority Contacted

{{item.type}} Department
{{item.name}}
{{item.reportNumber}}

Violations Issued
{{vm.data.accident.WereViolationsIssued}}

Claimant {{$index + 1}}

Last Name
{{item.lastName}}
First Name
{{item.firstName}}
Middle Initial
{{item.middleInitial}}
Phone (Home)
{{item.homePhone}}
Phone (Work)
{{item.workPhone}}
Ext
{{item.workPhoneExt}}
Email
{{item.email}}
Address

{{item.address.street}}
{{getAddress(item.address)}}

Date of Birth
{{item.dateOfBirth}}
SSN
*****
Loss Type
Bodily Injury
Property Damage
Vehicle Damage
Bodily Injury
Injury Description
{{item.bodilyInjury.injuryDescription}}
Property Damage
Property Description
{{item.propertyDamage.propertyDescription}}
Damage Description
{{item.propertyDamage.damageDescription}}
Damage Estimate
${{item.propertyDamage.damageEstimate}}
Vehicle Damage

Vehicle {{$index + 1}} Details

Vehicle
Year
{{item.vehicleDetails.vehicle.year}}
Make
{{item.vehicleDetails.vehicle.make}}
Model
{{item.vehicleDetails.vehicle.model}}
Color
{{item.vehicleDetails.vehicle.color}}
VIN
{{item.vehicleDetails.vehicle.vin}}
State Issued
{{item.vehicleDetails.vehicle.stateIssued}}
Plate
{{item.vehicleDetails.vehicle.plate}}
Is the Vehicle Damaged?
{{item.vehicleDetails.vehicle.isDamaged}}
Damage Description
{{item.vehicleDetails.vehicle.damageDescription}}
Is the Vehicle Driveable
{{item.vehicleDetails.vehicle.isDriveable}}
Vehicle Location
{{item.vehicleDetails.vehicle.location}}
Location Phone
{{item.vehicleDetails.vehicle.locationPhone}}
Is Driver same as owner
{{item.vehicleDetails.isDriverSameAsOwner}}
Vehicle Driver
Last Name
{{item.vehicleDetails.driver.lastName}}
First Name
{{item.vehicleDetails.driver.firstName}}
Middle Initial
{{item.vehicleDetails.driver.middleInitial}}
Email
{{item.vehicleDetails.driver.email}}
Phone
{{item.vehicleDetails.driver.phone}}
Extension
{{item.vehicleDetails.driver.ext}}
Date of Birth
{{item.vehicleDetails.driver.dateOfBirth}}
Driver License Number
{{item.vehicleDetails.driver.licenseNumber}}
License State
{{item.vehicleDetails.driver.licenseState}}
Address/Loss Location

{{item.vehicleDetails.driver.address.street}}
{{getAddress(item.vehicleDetails.driver.address)}}

Personal Property Damage
Was personal property damaged/stolen as a result of this loss?
{{item.vehicleDetails.personalPropertyDamage.wasPersonalPropertyDamaged}}
Description of Personal Property
{{item.vehicleDetails.personalPropertyDamage.propertyDescription}}
Damage Estimate
$ {{item.vehicleDetails.personalPropertyDamage.damageEstimate}}

Loss Details

Incident report only
{{vm.data.lossDetails.incidentReportOnly}}
Auto Dealer Claim
{{getAutoDealerDesc(vm.data.lossDetails.AutoDealerClaim)}}
Loss date
{{vm.data.lossDetails.lossDate}}
Loss Time
{{vm.data.lossDetails.lossTime}}
Address/Loss location

{{vm.data.lossDetails.lossLocation.street}}
{{getAddress(vm.data.lossDetails.lossLocation)}}

Accident Description
{{vm.data.lossDetails.accidentDescription}}
Authority Contacted

{{item.type}} Department
{{item.name}}
{{item.reportNumber}}

Violations Issued
{{vm.data.lossDetails.WereViolationsIssued}}

Vehicle {{$index + 1}} Details

Vehicle
Is this vehicle covered under a Zurich insurance policy?
{{item.vehicle.isVehicleInsuredByZurich}}
Year
{{item.vehicle.year}}
Make
{{item.vehicle.make}}
Model
{{item.vehicle.model}}
Color
{{item.vehicle.color}}
VIN
{{item.vehicle.vin}}
State Issued
{{item.vehicle.stateIssued}}
Plate
{{item.vehicle.plate}}
Vehicle used with owner's permission?
{{item.vehicle.OwnersPermission}}
Type of Vehicle
{{getVehicelType(item.vehicle.TypeOfVehicle)}}
Purpose of Use
{{item.vehicle.PurposeOfVehicleUse}}
Floor Plan / Loss Payee
{{item.vehicle.FloorPlanLossPayee}}
Floor Plan / Loss Payee Name
{{item.vehicle.LossPayeeName}}
Is the Vehicle Damaged?
{{item.vehicle.isDamaged}}
Damage Description
{{item.vehicle.damageDescription}}
Is the Vehicle Driveable
{{item.vehicle.isDriveable}}
Vehicle Location
{{item.vehicle.location}}
Location Phone
{{item.vehicle.locationPhone}}
Driver
Relationship To Insured
{{item.vehicle.RelationshipToInsured}}
Last Name
{{item.driver.lastName}}
First Name
{{item.driver.firstName}}
Middle Initial
{{item.driver.middleInitial}}
Email
{{item.driver.email}}
Phone
{{item.driver.phone}}
Extension
{{item.driver.ext}}
Date of Birth
{{item.driver.dateOfBirth}}
Driver License Number
{{item.driver.licenseNumber}}
License State
{{item.driver.licenseState}}
Address/Loss Location

{{item.driver.address.street}}
{{getAddress(item.driver.address)}}

Additional Insurance
{{item.vehicle.AdditionalInsurance}}
Additional Insurance Company
{{item.vehicle.AddlInsuranceCompanyName}}
Is Driver same as owner
{{item.isDriverSameAsOwner}}
Vehicle Owner Information
Last Name
{{item.owner.lastName}}
First Name
{{item.owner.firstName}}
Middle Initial
{{item.owner.middleInitial}}
Email
{{item.owner.email}}
Phone
{{item.owner.phone}}
Extension
{{item.owner.ext}}
Address/Loss Location

{{item.owner.address.street}}
{{getAddress(item.owner.address)}}

Injury Details
Was the driver injured?
{{item.injuryDetails.wasDriverInjured}}
Injury Description
{{item.injuryDetails.injuryDescription}}
Were any passenger injured?
{{item.injuryDetails.werePassengersInjured}}
Injured Passenger {{$index + 1 }}
Last Name
{{item1.person.lastName}}
First Name
{{item1.person.firstName}}
Middle Initial
{{item1.person.middleInitial}}
Email
{{item1.person.email}}
Phone
{{item1.person.phone}}
Ext.
{{item1.person.ext}}
Address/Loss Location

{{item1.person.address.street}}
{{getAddress(item1.person.address)}}

Injury Description
{{item1.injuryDescription}}
Personal Property Damage
Was personal property damaged/stolen as a result of this loss?
{{item.personalPropertyDamage.wasPersonalPropertyDamaged}}
Description of Personal Property
{{item.personalPropertyDamage.propertyDescription}}
Damage Estimate
$ {{item.personalPropertyDamage.damageEstimate}}
Pedestrian
Were any Pedestrians Injured?
{{vm.data.pedestrianDetails.werePedestriansInjured}}
Injured Pedestrian {{$index+1}}
Last Name
{{item1.person.lastName}}
First Name
{{item1.person.firstName}}
Middle Initial
{{item1.person.middleInitial}}
Email
{{item1.person.email}}
Phone
{{item1.person.phone}}
Ext.
{{item1.person.ext}}
Address/Loss Location

{{item1.person.address.street}}
{{getAddress(item1.person.address)}}

Injury Description
{{item1.injuryDescription}}

Property Damage

Was there any non-personal property damage?
{{vm.data.propertyDamage.anyNonPersonalPropertyDamaged}}
Property Damage {{$index + 1}}
Is this property covered under a Zurich Insurance policy
{{item.isPropertyInsuredByZurich}}
Property Owner Information
Last Name
{{item.propertyOwner.lastName}}
First Name
{{item.propertyOwner.firstName}}
Middle Initial
{{item.propertyOwner.middleInitial}}
Phone
{{item.propertyOwner.phone}}
Ext.
{{item.propertyOwner.ext}}
Email
{{item.propertyOwner.email}}
Address

{{item.propertyOwner.address.street}}
{{getAddress(item.propertyOwner.address)}}

Where is the property located?
{{item.wherePropertyLocated}}
Last Name
{{item.propertyLocationContact.lastName}}
First Name
{{item.propertyLocationContact.firstName}}
Middle Initial
{{item.propertyLocationContact.middleInitial}}
Address

{{item.propertyLocationContact.address.street}}
{{getAddress(item.propertyLocationContact.address)}}

Property Description
{{item.propertyDescription}}
Damage Description
{{item.damageDescription}}
Damage Estimate
${{item.damageEstimate}}

Witness

Witness {{$index + 1}}
Last Name
{{item.lastName}}
First Name
{{item.firstName}}
Phone
{{item.phone}}
Email
{{item.email}}

Property Loss

Loss Type (Peril)
{{vm.data.propertyLossDetails.lossTypeValue}}
Loss date
{{vm.data.propertyLossDetails.lossDate}}
Loss Time
{{vm.data.propertyLossDetails.lossTime}}
Address

{{vm.data.propertyLossDetails.lossLocation.street}}
{{getAddress(vm.data.propertyLossDetails.lossLocation)}}

Accident Description
{{vm.data.propertyLossDetails.accidentDescription}}
Has a restoration company been contacted
{{vm.data.propertyLossDetails.restorationCompanyContacted}}
Has your business been interrupted due to loss?
{{vm.data.propertyLossDetails.businessShutDown}}
Authority Contacted

{{item.type}}Department
{{item.name}}
{{item.reportNumber}}

Where was the property located?
{{vm.data.propertyLossDetails.wherePropertyLocatedValue}}
Property Location Address

{{vm.data.propertyLossDetails.propertyLocation.street}}
{{getAddress(vm.data.propertyLossDetails.propertyLocation)}}

Property Description
{{vm.data.propertyLossDetails.propertyDescription}}
Damage Description
{{vm.data.propertyLossDetails.damageDescription}}
Damage Estimate
${{vm.data.propertyLossDetails.damageEstimate}}

Additional Information

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Uploaded Attachments

{{item.name}}
{{item.description}}


State Questions

{{question.questionDesc}}
{{question.answer}}