KBS Claim Report Questionnaire

1.  * Select the option that best describes your purpose:
        I am first reporting a new claim to KBS I am adding information about a previously reported claim.

Tips:   
Do not admit fault or blame
If needed, help bring emergency assistance as soon as possible
Complete any KBS or company loss reports as soon as possible
Obtain contact information from witnesses
Protect property from further damage
Make damaged property available for inspection

2.  Basic Loss Information:
     * Date of Loss:    Time of Loss:
     * Location of Loss  (provide address if known)
       
     * Description of Loss  (what happened?)
       

3.  Policyholder and Contact Information:
     * Company Name:
        Policy Number (if known):  
     * Name of Person Reporting:
     * Title of Person Reporting:
     * Name of Person to Contact for More Info:  Check box if same as above
        
     * Title of Person to Contact for More Info:     Check box if same as above
        
     * Contact Phone:    Ext.    
     * Contact Fax:
     * Contact E-mail Address:

4.  Type of Claim:    Select Box and Click on Field of your choice to Proceed
         Auto 
         Workers Compensation
         General Liability
         Bicycle Liability
         Cargo / Warehouse
         Crime / Fidelity 'Bonding'
         Office Property
         Other

Auto Claim  Information:

1.  * Type of Loss: (check all that apply - hold down Ctrl key and click)
        Injury to Others Loss or damage to YOUR Vehicle Loss or damage to ANOTHER vehicle Loss or damge to other property

2.  * Loss involved Which Kind of Vehicle (check one)?
        Vehicle you own or lease Vehicle you rent (short-term) Driver-owned vehicle (owner-operator)

3.    Witness Information:
        Name:
        Address:
        Telephone Number:  
        --------------------------------------------------------------------------------------------
        Name:
        Address:
        Telephone Number:  

4.    Your Vehicle Information:    *Year:       
        *Make:        Model:
        *Vehicle ID No. (VIN):    
        *Plate No.:

5.    Your Driver Information:
        * Name:
           Address:
           Telephone Number:          

6.    Owner Information (if not already provided)
        * Name:
           Address:
           Telephone Number:       

7.    * Please send/fax KBS any police or accident reports as soon as possible.

        Depending on the Type(s) of Loss, Complete
        the Appropriate Sections Below: 

Auto Claim -- Injury to Others
     * Describe Injuries to Others (as much detail as possible)
       

    * Injured Party other than a driver (for drivers, see below):
       Name:
       Address:
                       
       Telephone Number:

Auto Claim -- Damage to Your Vehicle
     * Describe the Damage (as much detail as possible)
       

     * Where and when can your vehicle be seen? 
       

Auto Claim -- Damage to Another Vehicle
     * Describe the Damage (as much detail as possible)
       

     * Where and when can the other vehicle be seen? 
       

Auto Claim -- Damage to Other Property (not a vehicle)
     * Describe the Damage (as much detail as possible)
       

     * Where and when can the property be seen? 
       

    If the accident involved another driver and vehicle, complete
    the section below.  Otherwise, click "finish."

Other Driver & Other Vehicle Information:
1.  * Name:
2.    Address:
                       
3.  * Telephone Number:
4.    Drivers License Number:
4.  Insurance Company: 
5.  Insurance Policy Number: 
6.  Insurance Agent:
7.  Insurance Agent Telephone Number:
8.  Other Vehicle Information:
      *Year:       *Make:        
       Model:      Plate No.:  
       Vehicle ID No. (VIN):     

      Finish

Workers Compensation Claim Information:

1.  Claimant (i.e. Injured Worker) Information:
         * Name:
            Address:
            Telephone Number:
         * Sex:    Male    Female
            Date of Birth:
            Social Security Number:
         * Position / Title:
            Full-Time    Part-Time    Work Days per Week:

2.  * Describe Injury and identify body parts involved:
        

3.  * Has medical care been provided?    Yes    No
        First Aid        Emergency Room        Physician 

4.  * Will claimant miss work?    Yes    No    Unsure
         If yes, when was the last day worked?  
         Was claimant paid for the last day?    Yes    No

5.    Additional Notes (if any):
      

       Finish

General Liability or Bicycle Liability Claim Information:

1.  * Describe injury and property damage in detail  (unless already provided).
        

2.  Estimated Cost of Any Damages:  $

3.  * Where and when can any damaged property be seen? 
       

4.  Claimant Information:
         * Name:
            Address:
         * Telephone Number:

5.    Additional Notes (if any):
      

       Finish

Cargo or 'Bonding' / Courier Dishonesty Claim Information:

1.  * List and Describe Cargo Lost or Damaged.   
             

2.  * Estimate Cost to Replace Cargo Listed Above.   
             

3.   * Where and when can any damaged property be seen? 
       

4.  * Does the loss require reconstruction of documents or securities?
        Yes    No    Unsure at this time

5.  Customer Information
        * Name(s):
        

        * Address(es):
        

        Telephone Number(s):
        

6.  Driver Information:
        * Name:
           Address:
           Telephone Number:          

7.  * If the loss occurred over 3 days ago, explain the delay in reporting:
        

8.  * Please send/fax the following documents to KBS as soon as possible:
           written statement by driver
           police report (if any) -- theft must be reported to the police ASAP!
           claimant's request for reimbursement
           substantiation of cargo's value

9.    Additional Notes (if any):
       

        Finish    

Office Property Claim Information:

1.  * List and Describe Property Lost or Damaged.   
            

2.  * Estimate Cost to Replace Items Listed Above.   
            

3.   * Where and when can any damaged property be seen? 
       

4.  * Have Your Operations Been Suspended?    Yes    No
         If so, for how long?
         Estimate special expenses incurred to minimize down-time: $

5.  * Please send/fax KBS any police or fire dept. reports as soon as possible.

6.    Additional Notes (if any):
      

       Finish

Other Claim Information:

1.  * Describe Type of Claim:

2.    Additional Notes (if any):
      

       Finish

Thank you for reporting your claim.  KBS will do all we can to make
sure you are treated fairly and efficiently by your insurance carrier. 

>    Please follow instructions for sending documentation to KBS
>    Please watch for a confirming e-mail.  *Reports are not valid unless confirmed*
>    To contact KBS, call 1-888-KBS-4321  (8:30 AM - 6:00 PM EST)
>    To fax KBS: 914-636-0802
>    Return to complete a Claim Service Evaluation -- receive a FREE gift!

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