ACORD Forms : How to Complete a General Liability Notice of Occur form 3General Liability Notice of Occurrence/Claim 3
Use ACORD 3 to report both commercial and personal liability losses.
Month/day/year on which this form is completed.
Producer's name and address.
Phone (A/C, No, Ext)
Producer's telephone number.
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
If your agency uses a subcode identification system with the company, enter the appropriate code.
Agency Customer ID
Customer's identification number assigned by the agency.
Notice of Occurrence / Notice of Claim
Mark the appropriate block. Notice of Occurrence applies to both occurrence policies and to the report of incidents for Claims Made policies. The Notice of Claim applies only to Claims Made policies and is used for the reporting of suits or actual claims filed against the insured.
Date of Occurrence and Time
For Occurrence policies, enter the date and time of the incident. For Claims Made policies, enter the date and time that the insured discovered the event, incident, or accident which might later result in a claim being made. This date is important for establishing the applicable policy in extended reporting period/movement of retro date situations.
* After a Claims Made policy has been terminated, any claim may be valid if the incident occurred during the life of the policy and was reported within 60 days of its termination.
Date of Claim
This applies only to Claims Made policies. It is the date on which the actual suit was brought or claim filed against the insured. In many cases, this will be the same date that the insured first becomes aware of the incident, so both dates can be the same.
Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If it is not the first, list in the remarks section when other report(s) have been made.
Date on which the terms and conditions of the policy commenced.
Date on which the terms and conditions of the policy will or have expire(d).
Indicate whether the policy is written on an Occurrence or Claims Made basis.
This applies to Claims Made policies only. Enter the retroactive date indicated on the policy.
Name of the applicable insurance company and its' NAIC number. Do not use group names, use the actual name of the company within the group to which you are sending the loss notice.
Miscellaneous Information. Use this field to list site and location codes for large accounts or to enter the claim number on a phone-in report.
Number assigned by the insurance company for the policy.
Insured's claim number or other reference number to identify this notice.
Name & Address
Enter the name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if applicable,) of the insured as found on the declarations page of the policy.
For an individual, the home telephone number, including area code, of the insured.
The business telephone number, including area code and extension of the insured.
If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address and phone number.
Person to Contact
Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the "Contact Insured" option is checked.
Enter the home telephone number, including area code, of the contact named above. If it is the insured, leave this blank.
Enter the business telephone number, including area code and extension, of the contact. If it is the insured, leave this field blank.
Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).
Location of Occurrence
Give the physical location of the occurrence. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured's home or Loc 3, BLd 2; 151 Main St).
Enter the name of the municipal or county police or fire department to which the loss was reported. Include the precinct or station number if available.
Description of Occurrence
Describe the incident resulting in a potential loss to the insured.
Use this section to list the policy limits and deductibles as printed on the declarations page for the insured.
Coverage Part or Forms
Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, include a brief description of the endorsement.
Enter the limits for each applicable category. If coverage is not provided, enter N/A. Abbreviations are:
PROD./COMP-OP AGG.. . . . . . . Products/Completed Operations
PERS. & ADV. INJ . . . . . . . . . . . Personal and Advertising Injury
Enter the dollar amount of the deductible and indicate whether it applies on a Per Claim or Per Occurrence basis.
If the deductible applies to Property Damage (PD) or Bodily Injury (BI) check the appropriate box. For Combined Bodily Injury and Property Damage deductible, check PD & BI.
Indicate if such a policy is in force by checking the appropriate box.
The name of the Umbrella/Excess policy/carrier.
Enter the umbrella or excess policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the applicable self insured retention or deductible.
TYPE OF LIABILITY
This section is used to collect information about the type of exposure which has resulted in the damage or injury reported in this notice.
Premises: Insured is
Indicate the relationship of the insured to the premises by placing an "X" in the appropriate box. List the type when "Other" is checked.
Type of Premises
Give a brief description of the premises (e.g., mercantile with apartments).
Owner's Name & Address
If other than the insured, provide the owner's name and address. If this is the insured, enter "insured."
If other than the insured, provide the owner's telephone number, including area code and extension.
Products: Insured Is
For products coverage, indicate the business the insured is in by placing an "X" in the appropriate box. List the type when "Other" is checked.
Type of Product
Give a brief description of the insured's product (e.g., automobile parts, sales, appliances repair).
Manufacturer's Name & Address
If other than the insured, enter the manufacturer's name and address. If this is the insured, enter "insured."
If other than the insured, list the manufacturer's telephone number, including area code and extension.
Where Can Product Be Seen?
Indicate where the product can be inspected by the adjuster. If other than the insured's address, include the address.
Other Liability Including Completed Operations
Provide any additional pertinent information on the liability exposure. Also list any additional liability insurance carried by the insured. Include carriers, policy numbers, and limits.
Use this section to collect information on any injured party or any property damage.
Name & Address
Enter the name and address of any injured party, or owner of damaged property.
Enter the telephone number, including area code, of any injured party or owner of damaged properties.
Give the age of any injured person.
Indicate by "F"-Female or "M"-Male.
Enter a brief description of the injured person's occupation.
Employer's Name & Address
Enter the name and address of any injured person's employer.
Enter the employer's telephone number, including area code and extension.
Give a brief description of the injury. If fatal, check the available box.
Indicate where the injured was taken (e.g. St. Luke's Hospital, home).
What Was Injured Doing?
Briefly describe the activities of the injured person when the accident took place.
Give a brief description of any damaged property (e.g. printer # 31).
If known, give an estimate for the cost of repair to the damaged property.
Where Can Property Be Seen?
Indicate where the damaged property is located so the adjuster can inspect it.
When Can Property Be Seen?
Indicate the best time of day to inspect the damaged property (e.g., evenings, days, noon to 3:00 P.M.).
Use this section to identify any witnesses to the incident.
Name & Address
Enter the name and address of any witness.
Enter the witness's business telephone number, including area code and extension.
Enter the witness's residence phone number, including area code.
List any other additional information that will assist in properly reporting and settling this claim.
Indicate the name of the individual who reported the loss.
Indicate the name of the individual within the agency or company to whom this loss was reported.
Signatures of Producer and Insured
This form should be signed by the producer and the insured.
* Important state information is on the second side of this form.
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