Eldercare Occurrence & Claim The Hanover Insurance Company | 440 Lincoln … · 2017-03-08 ·...

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653 Citizens Insurance Company of America | 645 West Grand River Avenue, Howell, MI 48843 The information transmitted by this email or facsimile is intended for The Hanover Insurance Group. Other dissemination, distribution or copying is strictly prohibited. Please call (800) 831-9506 if you received this in error. This may be copied for risk management clients of The Hanover Insurance Group Healthcare Eldercare only. All rights reserved. Eldercare Occurrence & Claim Report Form There are three ways to submit: 1) Complete electronically and press submit for your form to be emailed directly to The Hanover Insurance Group; or 2) Complete and print form and email to [email protected]; or 3) Complete and print form and fax to (508) 926-1279 Policy Number: Date of report: Date of incident: Time of incident: Date aware of incident: Previously notified The Hanover Insurance Group or another insurance company? Yes No If yes, name of contact and date: Corporate Name: Facility Name: Address: City: State: Zip: Facility contact: Title: Phone: Fax: Email: Name of injured party: Male Female Date of birth: Date admitted to facility: Injured party status: Resident Visitor Level of Care: ILF ALF SNF Brief description of incident / alleged injury: Name of witness: Employee Resident Visitor Witness contact information: Disposition: Remained at home ER or Physician visit Hospital Admission Returned to facility – Date and Time: Name of family member notified: Relationship to injured party: Investigation by outside agency: Yes No Police State Federal Other: Name of person completing this report and contact info, if other than facility contact listed above: Page 1 of 2

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Transcript of Eldercare Occurrence & Claim The Hanover Insurance Company | 440 Lincoln … · 2017-03-08 ·...

Page 1: Eldercare Occurrence & Claim The Hanover Insurance Company | 440 Lincoln … · 2017-03-08 · Occurrence & Claim Report Form There are three ways to submit: 1) Complete electronically

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653 Citizens Insurance Company of America | 645 West Grand River Avenue, Howell, MI 48843

The information transmitted by this email or facsimile is intended for The Hanover Insurance Group. Other dissemination, distribution or copying is strictly prohibited. Please call (800) 831-9506 if you received this in error.

Eldercare Occurrence & Claim Report Form

There are three ways to submit:

1) Complete electronically and press submit for your form to be emailed directly to The Hanover Insurance Group; or 2) Complete and print form and email to [email protected]; or

3) Complete and print form and fax to (508) 926-1279 Policy Number:

Date of report: Date of incident: Time of incident: Date aware of incident: Previously notified The Hanover Insurance Group or another insurance company? Yes No If yes, name of contact and date: Corporate Name: Facility Name: Address: City: State: Zip: Facility contact: Title: Phone: Fax: Email: Name of injured party: Male Female Date of birth: Date admitted to facility: Injured party status: Resident Visitor Level of Care: ILF ALF SNF Brief description of incident / alleged injury: Name of witness: Employee Resident Visitor Witness contact information: Disposition: Remained at home ER or Physician visit Hospital Admission Returned to facility – Date and Time: Name of family member notified: Relationship to injured party: Investigation by outside agency: Yes No Police State Federal Other: Name of person completing this report and contact info, if other than facility contact listed above:

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