INCIDENT
REPORT FORM ( For Professional Liability Insurance )
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| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Home Phone |
|
| Work Phone |
|
| School Name |
|
| Grade Level |
|
| Subject Teaching |
|
| Please complete the following as it applies
to your circumstances: |
| Is this a report of a job action involving
your position? Yes
or No
|
| If NO, but you are reporting a possible liability
claim, answer ALL QUESTIONS below. Attach copies of any documentation you
have. |
| If YES, answer questions 1 and 2, skip 3 and 4 if appropriate,
and fill in the Brief Description Section below. Attach copies of any documentation
you have. |
| |
| Narrative of Report: (print legibly or type) |
| Date of notice/incident |
|
| Time of notice/incident |
|
| Names of witnesses |
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| Location of incident |
|
| |
Age of child
Sex of child
Grade level of child
|
Brief Description of Notice/Incident in Chronological Order:
|
| (attach additional sheets if necessary) |
| Complete and Return Form and Attachments
To: (Check only one)
Christian Educators Association International,
P.O. Box 45610
Westlake, OH 44145
Phone (440) 250-9566 -
Fax (440) 250-9584
Professional Liability Claim Department,
3130 Broadway, 4th Floor,
P.O. Box 418131
Kansas City, MO 64141-9131 -
Toll Free: (800) 821-7303 ext. 123 -
Fax: (816) 968-0600 Coverage is determined by the policy’s terms and the Claim Administrator’s
office will contact you about coverage after receipt of this information.
|
| Members Signature:__________________________ Date:______________
rev10/06 |