ESIS_Heading 1
PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE. RISK MANAGEMENT & INSURANCE OR A CLAIMS REPRESENTATIVE FROM GALLAGHER BASSETT WILL FOLLOW-UP WITH YOU REGARDING THE ACCIDENT. Date:Enter date.Email:Risk_mgmt@cornell.edu Christopher_Huggins@To:Gallagher Bassett Claims ReportingRe:FIRST REPORTS – NEW LOSS Pages (including cover) and attachments :Enter Number.**IN E-MAIL SUBJECT LINE: STATE NEW LOSS AND DATE OF ACCIDENT**, REQUIRED INFORMATION (please print):(Gallagher Bassett must have the following information in order to assist in the timely completion of the first report. Thank you.)(Gallagher Bassett only) Client Number:Enter Number.(Gallagher Bassett only) Client Name:Enter Name.Insured NameCornell UniversityDepartment Account # Department Name:Enter text.Fleet Vehicle #(Gallagher Bassett Only) Indicate Report Type (check one) ? Workers’ Compensation? Auto Liability? General Liability? Property & First Party Auto Claimant Name – If Applicable Enter Name.Claimant Email AddressEnter text.Claimant Cell NumberEnter Number.CLIENT CONTACT (Gallagher Bassett Only):Name:Enter Name.Phone Number:Enter Number.Cell Phone Number Enter Number.Email Address:Enter Email.LOSS/ ACCIDENT INFORMATION:Loss Location:Address:Description of Loss / Accident: CUPD – If responded, provide contact information:Outside Police Agency Respond? If so Police Dept. Information: CORNELL INSURED DRIVER: Name:Address:E-mail:Phone: Purpose of Use:If Injured, injury details:CORNELL INSURED VEHICLE:VIN:Year: Make: Model:Plate #:Description of Damage:Where is vehicle located?OTHER VEHICLE(S) INVOLVED IN THE ACCIDENT:Driver Information:Cell Phone Number:E-mail Address:Address:If Owner is different – Owner Contact information: Other Driver Injured? If so, injury details:Vehicle Information VIN:Year: Make: Model:Plate #:Description of Damage:Where is vehicle located?Passengers? If so provide contact information and Injury Information: Witnesses? If so provide each witnesses contact information:Other Remarks: ................
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