ISO CLAIM SEARCH REQUEST



ACS CLAIM SERVICE CLAIM SEARCH REQUEST

Please complete the following form OR attach the Employer’s Report of Occupational Injury or Disease (LIBC-344) and complete any information not included on the Employer’s Report.

|CLAIM |Claim Number: | |

|INFORMATION |ACS File # (if applicable) | |

| |Date/Time of Injury: | |

| |Policy Number: | |

| |Policy Type: | |

| |Policy Inception Date: | |

| |Policy Expiration Date: | |

| |Location of Loss With Address: | |

| | | |

| |Loss Description: | |

| | | |

|INSURED |Name: | |

|INFORMATION |Address: | |

| | | |

| |Phone #: | |

| | | |

|CLAIMANT |Name: | |

|INFORMATION |Address: | |

| | | |

| |Date of Birth: | |

| |Gender: | |

| |Home Phone: | |

| |Social Security #: | |

| |Occupation: | |

| | | |

|COVERAGE |Coverage Type: | |

|INFORMATION | | |

| |Loss Type (check one): |( Indemnity ( Medical Only |

| | | |

| |Claim Status: |( Open ( Closed ( In Litigation |

| |(check all that apply) |( Subrogation Pending |

| |Adjuster Name: | |

| |Adjuster Phone: | |

| |Alleged Injury: | |

| |Part of Body: | |

| | | |

|OTHER |Name: | |

|(i.e. claimant attorney) |Address: | |

| | | |

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