Claims Reporting Reference Guide

Claims Reporting Reference Guide
Gallagher
2850 Golf Road
Rolling Meadows, IL 60008-4050
630.773.3800
www.ajg.com
© 2019 Arthur J. Gallagher & Co.

CLAIMS REPORTING REFERENCE GUIDE
Table of Contents
SECTION PAGE
Coverages ......................................................................................................................................................................................... 1
Workers’ Compensation ............................................................................................................................................................. 1
Automobile Liability..................................................................................................................................................................... 2
General Liability .......................................................................................................................................................................... 3
Property ...................................................................................................................................................................................... 4
Boiler, Machinery & Equipment Breakdown ............................................................................................................................... 4
Professional Liability/Errors and Omissions Coverage ............................................................................................................... 5
Cyber Insurance ......................................................................................................................................................................... 6
Employment Practices Liability ................................................................................................................................................... 7
Directors & Officers Liability Coverage ....................................................................................................................................... 8
Crime Coverage ......................................................................................................................................................................... 9
Fiduciary Liability Coverage...................................................................................................................................................... 10
Avoid Coverage Disputes ......................................................................................................................................................... 11
Accident Investigation ...................................................................................................................................................................... 13
What to do when there is an incident/accident ......................................................................................................................... 13
Sample Forms ................................................................................................................................................................................. 16
Employer’s First Report of Injury Form ..................................................................................................................................... 17
Employee’s Report of Injury Form ............................................................................................................................................ 18
Supervisor Accident Investigation Form ................................................................................................................................... 19
Witness Statement ................................................................................................................................................................... 20
Accident/Incident Investigation Report ..................................................................................................................................... 21
Authorization for the Release of Medical Information ............................................................................................................... 23
Auto Accident Report Form ...................................................................................................................................................... 24
General Liability Incident Report Form ..................................................................................................................................... 26
Property Damage Report Form ................................................................................................................................................ 27
Inland Marine/Cargo Transit Incident Report ............................................................................................................................ 28
Disclaimer:
Gallagher provides risk services consultation that is tailored to our clients’ particular loss history, industry risk factors, and insurance program structure. Our
services, summaries and recommendations can include claim advocacy, evaluation of loss frequency and severity, loss prevention strategy, sufficiency of self-
insured retentions, risk transfer options, identification of risk exposures, and insurance coverage for particular claims. Our work can also include collaboration with
carriers, our client’s legal counsel, loss prevention or actuarial consultants. We emphasize that any of the above risk services, risk management opinions, and
advice provided directly to clients or to clients’ third-party vendors, is both confidential and intended for our clients’ use and not for distribution. We also only offer
the advice from an insurance/risk management perspective and it is NOT legal advice or intended to supplant the advice or services provided to clients from legal
counsel and advisors. We recommend that our clients seek advice from legal counsel and third-party professionals to become fully apprised of all legal and
financial implications to their businesses.
Many factors affect coverage of claims. While appropriate notice to insurers is mandatory, notice does not guarantee coverage, which is governed by the terms
and conditions of the relevant policy or policies. Nothing in this summary supersedes your policy language, which must be consulted to determine coverage.
Gallagher does not monitor the erosion of policy limits. In addition, insurers may change their contact information without notice.
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M-Forms\Claims Reporting Reference Guide
Coverages
Workers’ Compensation
DEFINITION:
• Provides medical treatment and wage replacement coverage for on-the-job injuries or work-related injuries or illness.
WHAT TO DO:
• Immediately report the claim to the insurance carrier/TPA and notify the excess carrier if necessary.
• Be sure to complete an Employer’s First Notice of Injury.
• Direct the injured worker to an approved medical facility, each location should have a list of approved or preferred providers.
• Investigate the accident internally, interview employee, witnesses, gather all facts and take photographs.
• If you have an employee involved in a vehicle accident while on the job and there is vehicle damage, be sure to file an Auto
Liability claim as well.
• Correct hazards immediately.
• Some types of serious injuries may also require notice to OSHA. Utilize modified / light-duty whenever possible; the best
option is to keep the employee at work or limit time off.
• Maintain contact with injured worker and the claims adjuster until the employee is back to full capacity.
• Medical bills and medical reports should be mailed directly to your carrier/TPA. Be sure to include the claim number, employee
name and date of injury on your communication.
• Should you have a problem with any claim, unpaid bills or delay in disability payments, call your adjuster for assistance.
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Automobile Liability
DEFINITIONS:
Automobile Liability
Coverage in the event of bodily injury or property damage arising out of the ownership, maintenance or use of an insured
automobile.
Auto Physical Damage

Coverage in the event an insured's owned automobile is damaged, destroyed, or lost through fire, theft, vandalism, malicious
mischief, collision, or windstorm.
Hired Automobile Liability

Coverage for liability to others for property damage or bodily injury caused by autos which are leased, hired, rented or borrowed for
use in the named insured’s business. This includes things like pool cars, leased vehicles and rental cars.
Nonowned Automobile Liability

Coverage for liability to others for property damage or bodily injury caused by autos owned by the insured’s employees, when in
use for the named insured’s business.
Underinsured/Uninsured Motorist
Provides coverage for bodily injury (and in some states property damage) when an accident is caused by a motorist who is not
sufficiently insured or does not have insurance.
WHAT TO DO:
• Immediately report the claim to the insurance carrier / TPA and notify the excess carrier if necessary.
• Do not discuss the accident with the other party nor admit fault for an accident.
• Advise anyone involved that you will report the accident to your insurance carrier.
• Determine if there are injuries and if necessary, seek medical attention.
• If possible, photograph damage to any vehicles involved.
• Immediately contact the local authorities and file a police report; be sure to document the report number. If possible, obtain a
copy of the report.
• Obtain information from the adverse party; name, address, home and work phone numbers and e-mail.
• Obtain information on all witnesses; names, address, home and work phone numbers and e-mail.
• Report all collected information to your immediate supervisor.
• Remember that insurance companies require an opportunity to examine the damaged vehicle. Do not authorize repairs or
dispose of a vehicle without first contacting the adjuster handling your claim.
• If you have an employee involved in a vehicle accident while on the job and they are injured, be sure to file a Workers’
Compensation claim, as well.
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General Liability
DEFINITION:
Provides defense and indemnity on covered claims for legal liability to others arising from bodily injury, property damage, personal
injury, and advertising injury. This generally covers two types of exposure: premises operations – where a customer or other non-
employee is injured on your property such as a slip and fall and products liability, where something you manufacture, sell or
distribute causes injury, illness or damage.
WHAT TO DO:
• Immediately report the bodily injury or damage to property of others to the insurance carrier and notify the excess carrier if
necessary.
• Determine if there are injuries and if necessary, seek medical attention.
• Take photos and inspect the area noting any conditions that may be pertinent to the accident. Preserve any video or
surveillance footage that might be available.
• Preserve and maintain any item involved in the incident, such as a piece of equipment or property.
• Obtain information from the claimant party; name, address, home and work phone numbers and e-mail.
• Obtain information on all witnesses; names, address, home and work phone numbers, and e-mail.
• If needed, file and obtain a police report.
• Do not admit fault or make any promises to pay or compensate an injured party.
• Do not discuss the claim with any other insurance carrier; refer them to your adjuster.
• Do not assume responsibility for any medical bills or property damage.
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Property
DEFINITION:
Coverage to protect the insured’s buildings, property and contents from covered loss perils.
WHAT TO DO:
• Immediately report the claim to the insurance carrier and notify the excess carrier if necessary.
• Whenever possible, take pictures of damaged area before starting temporary repairs.
• Make necessary repairs, as needed, to protect the property from further damage.
• Retain damaged property for inspection by insurance company adjuster.
• Keep area safe after a loss.
• Obtain detailed repair estimates and provide them to the carrier.
• If needed, file and obtain a police report.
Boiler, Machinery & Equipment Breakdown
DEFINITION:
Coverage for loss caused by mechanical or electrical equipment breakdown, including damage to the equipment, damage to other
property of the insured and damage to property of others.
WHAT TO DO:
• Immediately report the claim to the insurance carrier and notify the excess carrier if necessary.
• Whenever possible, take pictures of damaged area before starting temporary repairs.
• Make necessary repairs, as needed, to protect the property from further damage.
• Retain damaged property for inspection by insurance company adjuster.
• Obtain detailed estimates for repairs.
• Obtain expert reports (i.e., engineer, cause and origin, metallurgy, etc.)
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Professional Liability/Errors and Omissions Coverage
DEFINITION:
Insurance that provides coverage for an entity and its professionals for the services that they provide. Coverage is provided for any
actual or alleged negligence and failure to provide or perform professional services. Policies specifically define and list services
that are covered on the policy making each form unique.
WHAT TO DO:
• Each policy defines “Claim.” Please review the definition of “Claim” in context with the reporting requirements.
• Each carrier’s policy can vary on the time requirements so we recommend that claims be reported immediately. If you have a
claim and do not immediately notify the carrier, there is a potential that coverage will not be provided.
• Do not offer to settle a claim or hire an attorney without the carrier’s prior consent. Do not offer to compromise or settle any
claim or demand without the carrier’s prior agreement, or you will risk losing coverage. Do not engage in ‘ballpark’ settlement
discussions without the carrier’s involvement.
DUTY TO DEFEND POLICY:

If your policy is a duty to defend policy, the carrier has the right to hire an attorney(s) to defend the claim. If you hire your own
attorney, you may jeopardize coverage, and the carrier may replace your chosen attorney in order for legal fees to be covered. If
you hired an attorney without carrier consent, your legal bills could also be denied.
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Cyber Insurance
DEFINITION:
Generally, Cyber insurance provides reimbursement or payment of the insured’s own costs associated with an event covered by
the policy. Typically, this event can be a breach, a hacking, or a ransomware situation. Cyber coverage also responds to liability
claims made against the insureds in connection with a privacy breach event.
BREACH RESPONSE NOTIFICATION REQUIREMENTS

At the time of a breach, the following steps should be taken to properly position your organization to respond to a breach as well as
to ensure that insurance will apply:
• Report the matter to the insurance carrier. Do not engage any vendor or professional (see below) without obtaining the
express consent of the adjuster. Failure to use insurer-approved vendors can result in the claim not being covered.
• Contact your approved breach response attorney immediately to establish attorney/client privilege and to begin the process of
investigating the incident.
• The breach response attorney will work with you to ensure all potentially relevant information and documentation is preserved
and protected from destruction.
• Retain an approved forensic investigator with the guidance of the breach response attorney.
• The breach response attorney will engage the forensic investigator on behalf of your company to protect the exchange of
information under attorney/client privilege.
• Notify your insurance broker. The notice should include all facts available at the time of the notice.
• Many insurance companies have a 24-hour cyber breach hotline that will allow for immediate direct interaction with the
insurance company, which is especially important if prior approval is required before engaging a breach attorney and forensics
investigator.
INITIAL COVERAGE EVALUATION

• Expect to receive an initial acknowledgement of the claim from the cyber insurance company.
• Generally, within 30 days or soon thereafter, a formal claim evaluation will be provided by the insurance company determining
if coverage is available for the claim.
• The insurance company will follow up, as needed, for additional information about the breach.
• The insurance company will provide confirmation of the approved service providers (if any) and the scope of services.
POST-BREACH LITIGATION
• A breach often leads to litigation brought by the parties impacted by the breach.
• If litigation results from a breach, it is important that a comprehensive breach response plan has put your organization in a
defensible position.
• Choose qualified defense counsel pre-approved or allowed by your insurance company. Interview several firms and choose
two to three qualified firms in order of priority should a conflict exist. The breach response attorney may also serve as defense
counsel with carrier approval.
• It is essential that proper measures are taken before litigation to ensure that potentially relevant information and
documentation is preserved and protected from destruction.
Please keep your Gallagher advisor updated about the status of any breaches or claims.
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Employment Practices Liability
DEFINITION:
Employment Practices Liability insurance protects the insured’s balance sheet by covering the entity, directors, officers and
employees for any actual or alleged employment practices wrongful act. The definition of an employment practices wrongful act is
extremely broad and typically covers a variety of actions including but not limited to wrongful termination, discrimination,
harassment and a variety of other actions.
WHAT TO DO:
• Claims must be reported immediately. If you have a claim and do not immediately notify the carrier, you may lose all potential
coverage. “Claims” are typically defined broadly and may include demands for monetary or non-monetary relief.
• If you have Employment Practices coverage, a notice of charges to the EEOC or a state agency may be a claim and it must be
submitted to the carrier immediately – even if the matter seems informal or preliminary.
• Do not offer to settle a claim, or hire an attorney, without the carrier’s prior consent. Do not offer to compromise or settle any
claim or demand without the carrier’s prior agreement, or you will risk losing coverage. Do not engage in ‘ballpark’ settlement
discussions without the carrier’s involvement.

If your policy is a duty to defend policy, the carrier has the right to hire an attorney(s) to defend the claim. If you hire your own
attorney, you may jeopardize coverage, and the carrier may replace your chosen attorney in order for the claim to be covered.
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Directors & Officers Liability Coverage
DEFINITION:
Insurance protection written for an entity’s directors and officers for any actual or alleged wrongful act. Coverage may also apply to
the entity itself. Directors & Officers Liability insurance (D&O) is a highly negotiable coverage. Policies vary widely and the specific
policy, with endorsements, must be consulted in every instance. There is no “standard” policy.
Coverage is triggered by a “Claim” as defined by the policy, which is typically an allegation of as wrongful act, as defined by the
policy. Wrongful acts may include, but are not limited to, allegations of improper disclosures, breach of fiduciary duty, fraud,
misstatements, misleading statements and inadequate merger consideration.
There are three components of Directors & Officers Liability coverage, Side A, B and C. Some policies include a fourth component,
Crisis Management coverage.
Side A coverage responds to the loss of an insured individual, which has not been or cannot be indemnified. There is usually no
retention for Side A. Some policies include a Presumptive Indemnification provision, which can convert a Side A claim to a Side B
claim, even if the claim is not indemnified.
Side B responds to reimbursing the insured organization for its indemnification obligation to an individual insured on a covered
claim. While the language is often couched in terms of “reimbursement” in most events, the entity generally need not advance the
reimbursement.
Coverage under Side C for a public company’s own liability is usually limited to securities claims, as defined by the policy. Private
company forms usually offer broader coverage for the entity’s own liability. The policy’s specific terms and conditions must be
consulted in every event.
WHAT TO DO:
A claim can be a shareholder derivative action, a direct shareholder action, or a merger objection claim. A claim may include,
under most forms, lawsuits, arbitrations and some (but not all) investigations and criminal indictments. Some policies specifically
include a request for mediation or tolling of the statute of limitations in the definition of claims.
Notice to the carrier is crucial. If an insured has a claim and does not immediately notify the carrier, it jeopardizes coverage. It may
also be possible to provide notice of facts which could give rise to a claim in the future.
Because of the complexity of D&O coverage, insureds should maintain a systematic review process to assure that coverage is not
lost because a claim has been overlooked.
DUTY TO DEFEND V. NON DUTY TO DEFEND POLICY:

Defense provisions in a D&O policy can be complex. Some D&O policies provide that the insurer has the right and duty to defend a
claim, which imposes a broad obligation to on the carrier. Other policies impose a duty of reimbursement and/or advancement on
the carrier, which is generally considered narrower than a duty to defend. Further, the carrier may demand an allocation of defense
and indemnity payments, which can further reduce the insurer’s obligation.
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Crime Coverage
DEFINITION:
Crime insurance provides coverage within the carious insuring agreements for the insured’s loss arising directly from dishonest
acts committed by employees or outsiders against the insured organization. Coverage may include some or all of the following
insuring agreements, but check your policy to determine the specific scope of coverage:
• Theft (not all theft triggers coverage).
• Forgery (not all forgeries trigger coverage).
• Destruction or disappearance of money or securities on the insured’s premises, banking premises or in transit.
• Loss due to robbery or attempted robbery.
• Third-party money order and counterfeit currency fraud.
• Dishonest acts (not all dishonest acts trigger coverage) against an insured’s client by the insured’s employee on- and off-
premises.
• Theft from a named executive’s personal account.
• ERISA fiduciary bonds (different than Fiduciary Liability coverage).
Coverage will vary by policy, but general guidelines for all policyholders:
• Claims and covered events should be reported immediately upon discovery. Do not wait to quantify the loss.
• Late notice may jeopardize coverage.
• Crime carriers may require written notice as soon as practicable, and no later than sixty or ninety days after discovery of a
situation that may give rise to a claim.
• Discovery is generally defined as an executive or insurance representative becoming aware of facts which would cause a
reasonable person to assume that a crime loss has occurred.
• Crime carriers typically require a sworn proof of loss with complete details typically no later than six months after discovery.
Some policies provide coverage for the expenses associated with determining the quantum and method of loss.
It is important to remember that a crime policy is not a liability policy; it does not protect the insured against claims by a third party.
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Fiduciary Liability Coverage
DEFINITION:
Insurance written to cover fiduciaries of employee benefit plans. An insured under these plans can also include an employee,
director, officer of the plan or the insured organization itself acting with the trustee’s authorization. Coverage is written primarily for
the administration of the plan(s), and in most cases the plans are governed by ERISA. Fiduciary Liability insurance may also
include coverage for creating the plan, called Settlor Liability coverage. Insured plans generally include, but are not limited to,
pensions, 401K, profit-sharing, and group health plans. Multiemployer plans and ESOPs may also be covered.
Wrongful acts can be allegations by beneficiaries for imprudent investment vehicles, alleged mismanagement of the plan, breach
of trust, duty, statute, maladministration, neglect, misstatement, administrative error or omission. There may also be an Errors &
Omissions component to the Fiduciary Liability insurance, triggered by an allegation of error in the enrollment, administration or
counseling participants of the program.
As with all Management Liability coverage, policies vary. The policy must be consulted for specific terms and conditions.
WHAT TO DO:
• Coverage is triggered by a “claim” as defined by the policy. It can be a demand by plan beneficiaries or a beneficiary’s estate.
It may also be a contribution notice issued by the pensions regulator, an extradition proceeding, or any administrative or
regulatory proceeding or official investigation brought against an insured based on a wrongful act in an insured capacity.
• Policies vary on the time requirements so we recommend that claims be reported immediately. If you have a claim and do not
immediately notify the carrier, you jeopardize coverage.
• If the carrier has not agreed in writing, in advance, to an expense, coverage may not be provided. Even casual settlement
discussions without prior consent may violate the policy.

If your policy is a duty to defend policy, the carrier has the right to hire counsel to defend the claim. If you hire your own attorney,
without the carrier’s express permission, you may jeopardize coverage. The carrier may replace your chosen attorney and refuse
to pay all fees to which it has not consented.
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Avoid Coverage Disputes

Customized Analysis and Quality Solutions for All Clients
The most common claim disputes involving claims-made policies stem from late notice or incurring defense or settlement expenses
without proper consent of the insurer. We will review these issues to help avoid coverage disputes and prevent financial burden in
the event of a claim that is denied.
NOTICE IMPLICATIONS OF “CLAIMS-MADE” POLICIES

With few exceptions, Management Liability policies are written on a “Claims-Made and Reported” basis. This means coverage
applies only to a claim first made against you during the policy period and reported to the carrier within the time specified in the
policy. This should be viewed as the first two fixed conditions of coverage; unless the claim is first made during the policy period
and reported as required, there will be no coverage.
Thus, timing of notice is crucial, as it is a condition precedent of coverage. Most policies require notice “as soon as practicable”
during the policy period while others specify a required time frame (e.g., within 60 days).
WHAT CONSTITUTES A “CLAIM?”

Given that the consequences of not reporting a claim within the time frame required by the policy is serious and may lead to the
denial of a claim, it is important to understand what constitutes a “claim.”
There can be significant differences among policy forms with some definitions of “claim” being more broad or narrow than others.
Below are samples of claim definitions found in two common Management Liability policy forms and a discussion of related issues
(note: your policy wording may differ).
Directors and Officers Liability Employment Practices Liability
“Claim” means: “Claim” means:

i. A written demand for monetary, non-monetary or injunctive i. A written demand or notice for monetary or non-monetary
relief; relief;
ii. A civil proceeding; ii. A civil proceeding;
iii. A criminal proceeding; or iii. An arbitration or formal administrative or regulatory
iv. A formal administrative or regulatory proceeding. proceeding, including but not limited to a proceeding
before the Equal Employment Opportunity
Commission (EEOC), and or similar state agency,
brought by an employee or an applicant for employment
with the company.
The definition of a claim can be different, and include not only formal litigation as a claim, but also any written demands for
monetary or non-monetary relief. The receipt of a claim triggers reporting conditions under the policy. For this reason, it is
important to notify the carrier of everything that may meet the definition of claim under the policy, including, for example, all EEOC
complaints, even if they appear frivolous or without merit.
NOTIFYING THE CARRIER OF A CLAIM

Most policies impose a duty upon the insured to notify the carrier of a claim. The policy requires that the insured notify the carrier of
a claim directly by phone, electronically or in writing and will also specify where to direct the claim and any additional information
needed by the carrier. The notification should be written on company letterhead, and forwarded with proof of mailing or return
receipt. If the policy allows for notification via email, we recommend maintaining a hard copy.
Provide your Gallagher advisor with a copy of the notification of the claim so that we may monitor the status of your claim.
CARRIERS TO NOTIFY
If you carry multiple layers of coverage, notice must be given to all excess carriers when you notify the primary carrier.
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SELECTION OF COUNSEL
Selection of counsel is dictated by the policy. If it is a “duty to defend” policy, the carrier will select the counsel, although the policy
may provide for your approval, or you may have negotiated a particular firm in advance. If it is a “reimbursement” policy, you may
retain your own counsel, subject to the carrier’s approval of the firm and rates charged.
Some reimbursement policies restrict choice of counsel to the carrier’s list of pre-approved law firms (panel counsel). If panel
counsel is required by your policy, the carrier will not reimburse fees or costs of non-approved counsel or “off-panel” counsel.
CARRIER CONSENT
The carrier should be kept apprised of the status of any litigation, and consent must be obtained prior to any settlement
discussions or negotiations. This is required by the cooperation obligation under the policy. Your lawyer must work with the claims
adjuster to obtain settlement authority. This is best achieved by keeping the adjuster updated on the status of the litigation.
CONCLUSION
Reporting a potential claim promptly and in accordance with the duties set forth in the policy will ensure access to the coverage
provided by the insurance policy. Establishing a good working relationship with your carrier from the outset will facilitate the claims
process and the resolution of your claim.
Let your Gallagher advisor know about any changes in the status of a claim, or any issues relating to coverage or claims handling.
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Accident Investigation
What to do when there is an incident/accident
When an accident occurs, it is imperative an accident investigation be conducted. The main purpose of an accident investigation is
to collect facts. Based on the information collected, the investigators should draw conclusions to identify the causes of accidents
and provide corrective action to prevent future accidents.
There is a difference between simply reporting accidents and investigating accidents. To report an accident, one must collect
information such as the injured person’s name, date and time of injury, department, the person’s address, social security number,
and date of birth. To investigate an accident, the investigator must obtain more detailed information, including a description of the
accident and its potential causes, and analyze all causes contributing to the accident. In other words, an accident investigation
should answer the following questions: WHO, WHAT, WHERE, WHY AND HOW.
Accident Investigation & Problem Solving Guide

Machine Breakdown Person Breakdown (Injury)
• Who reacts? • Who reacts?
• How fast? • How fast?
• Are causes seen as operation issues or people issues? • Are causes seen as operation issues or people issues?
• Do corrective actions seek operational improvements? • Do corrective actions seek operational improvements?
• What are the benefits from the corrective actions? • What are the benefits from the corrective actions?
• Are fixes Band-Aids or permanent? • Are fixes Band-Aids or permanent?
“Person Breakdowns” should be given as much, if not more,

attention than machine breakdowns.
Consider the entire cost of an accident: loss of production, loss of quality, someone replaces injured worker, someone takes
injured worker to hospital, administrative costs, loss of skilled individual during recovery.
Accident investigations provide OPPORTUNITIES to identify root causes, eliminate job hindrances and better control
operations.
Root Cause: the end of the “WHY?” process. Ask “WHY?” at least four times in an investigation.
Job Hindrance: A situation, condition, or event that interrupts or interferes with the orderly progress of a job. Sometimes called
a “bottleneck.”
Benefits of Effective
Investigations
• Build a safety culture by reacting to employee concerns
• Prevent recurrence of similar accidents or incidents
• Identify better methods of doing something
• Control operations. “Operations” includes every facet of the process involved in assuring that the product or service is
efficiently produced or provided. Operations Control is making sure that the above result is achieved. Operations Control
may include scheduled preventive maintenance, training, planning operations and controlling accidents.
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Definitions
Responsible Condition The condition(s) that, if eliminated, should result in no further repetition of the particular loss or
accident under the same set of circumstances; sometimes referred to as the root cause.
Accident An undesired event that results in harm to persons, damage to property, or both, usually
occurring suddenly and unexpectedly, but sometimes having taken significant time to reach the
point of occurrence. Accidents can be major job hindrances.
Incident Like an accident, an undesired event, usually occurring suddenly and unexpectedly, but without
resulting in harm to persons or damage to property, sometimes referred to as a near mishap.
The Only Difference Between an Accident and a Near Mishap...... are Time and Space!
Incident Investigation Tips

• Investigate the problem. Begin ASAP!
• Determine the root cause.
• Engage in fact finding, not fault finding. (NO “blame storming”)
• Gather and record raw information
• Carefully interview all witnesses
• Corroborate and verify all information
• Develop solutions (discussed with employees before implementing)
• List how the injury risk is reduced
• List how the operation is improved
• Investigate — don’t report. Use the 6 Ws.
EMP — Common in Every Operation

Equipment Material People
Select Select Select
Arrange Place Place
Use Handle Train
Maintain Process Lead
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Using the Six “Ws

WHY? Was it necessary?
WHAT? What useful purpose does it serve?
WHERE? Where should it be done?
WHEN? When should it be done?
WHO? Who is best qualified to do the job?
HOW? How can the job be done better, easier, safer?
“WHAT?” and “WHY?” can eliminate a step.
Get all the facts by studying the job. Study the job, not just the accident. Ask “WHY” four times.
Why did they take a shortcut (for instance)? Were they trained? Were they confused or tired?
If the hazard was allowed to exist —ignored— who committed the unsafe act?
Ignoring a behavior reinforces the behavior!
“WHEN?”, “WHERE?” and “WHO?” can combine or rearrange steps or details.
Describe the injury or problem in simple terms. Ask more questions if needed.
“HOW?” can simplify the process.
How could the job have been done differently and how can it be changed.
Changes MUST NOT make a situation MORE dangerous!
FOLLOW-UP is VITAL
Record what you have done.
Record what still needs to be done.
Assign responsibility.
Assign a target date.
Will actions apply somewhere else?
FOLLOW UP AT SET INTERVALS: LOG > REVIEW > ACT
Have the hazards been eliminated or reduced?
Has the operation been improved?
If not, ask more questions!
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Sample Forms
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Employer’s First Report of Injury Form

DATE OF REPORT CASE OR FILE # IS THIS IS A LOST WORK DAY CASE?
Yes No
Employers Name Doing Business As
Employer’s Mailing Address Employer’s E-mail Address
Nature of Business or Service SIC Code
Name of Workers Compensation Carrier/Administrator Policy/Contract # Self-Insured?

Yes No
Employee’s Full Name Birthdate
Employee’s Mailing Address Employee’s E-mail Address
Gender Marital Status # of Dependents Employee’s Average Weekly Wages

Male Female Married Single $
Job Title or Occupation Date Hired
ACCIDENT INFORMATION
Time employee began work Date and time of incident Last day employee worked
If the employee died as a result of the accident, give the date of death. Did the accident occur on the employer’s premises?
Yes No
Address of Accident
What was the employee doing when the accident occurred?
How did the accident occur?
What was the injury or illness? List the part of body affected and explain how it was affected.
What object or substance, if any, directly harmed the employee?
Name and address of physician/healthcare professional.
If treatment was given away from worksite, list name and address of the place it was given.
Was the employee treated in an emergency room? Was the employee hospitalized overnight as an inpatient?
Yes No Yes No
SIGNATURES
Report Prepared By Signature Title and Telephone # E-mail Address
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Employee’s Report of Injury Form

INSTRUCTIONS
Employees shall use this form to report all work-related injuries, illnesses, or “near miss” events (which could have caused an injury or illness)
– no matter how minor. This helps to identify and correct hazards before they cause serious injuries. This form should be completed by the
employee as soon as possible and given to a supervisor for further action.
REQUIRED INFORMATION
I am reporting a work-related Injury Illness Near Miss
First Name Middle Name Last Name Date of Birth Date of Hire
Social Security
Number Phone Number Address City State Zip
Job Title Department Supervisor’s Name Date of Injury/Near Miss Time of Injury/Near Miss
Have you told your supervisor about this injury/near miss? Yes No When:
Names of witnesses (if any):
Where, exactly did it happen?
What were you doing at the time?
Describe step by step what led up

to the injury/near miss. (Continue
on another sheet if necessary.)
What could have been done to

prevent this injury/near miss?
What parts of your body were

injured? If a near miss, how could
you have been hurt?
Did you see a doctor about this injury/illness? Yes No When:
Doctor’s Name: Doctor’s Phone Number:
Has this part of your body been injured before? Yes No If yes, when:
SIGNATURES
Print Name Signature
Employee Date
Supervisor Date
Page 18
Supervisor Accident Investigation Form

INJURED PERSON’S INFORMATION
Type of Information Injury Illness Near Miss
First Name Middle Name Last Name Date of Birth Date of Hire
Social Security
Number Phone Number Address City State Zip
Date of Injury/
Near Miss Time of Injury/Near Miss Exact Location of Event
What part of the body was injured?

Describe in detail.
What was the nature of the injury?

Describe in detail.
Describe fully how the accident

happened? What was employee
doing prior to the event? What
equipment, tools being using?
What caused the event?
Were safety regulations in place

and used? If not, what was wrong?
What could have been done to

prevent this injury/near miss?
Recommended preventive action to

take in the future to prevent
reoccurrence.
Were there any witnesses?
Did the Employee go to doctor/hospital? Yes No When:
Doctor/Hospital Name: Doctor/Hospital Phone

Number:
SIGNATURES
Print Name Signature
Supervisor Date
Human Date
Resources
Page 19
Witness Statement
In reference to the industrial injury involving
that occurred on the day of 20 please answer the following questions:
1. What first drew your attention to the accident?
2. Did you actually see the accident happen? Yes No
If yes, answer the following questions:
A. Give exact location of accident.
B. Where were you standing at the time of the accident?
C. How far away from the injured person were you at the time of the accident?
D. Were you facing the person who was injured at the time of the accident? Yes No
Give complete details of what you saw happen:
SIGNATURES
Name Printed Date
Signature Department
Page 20
Accident/Incident Investigation Report

INSTRUCTIONS
Complete this form as soon as possible after an incident that results in serious injury or illness. (Optional: Use to investigate a minor injury or
near miss that could have resulted in a serious injury or illness.)
This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss
Date of Incident: This report is made by: Employee Supervisor Team Other _______________
STEP 1: Injured employee (complete this part for each injured employee)
Name: Sex: Male Female Age:
Department: Job title at time of incident:
Part of body affected: (shade all that apply) Nature of injury: (most serious one) This employee works:
Abrasion, scrapes Regular full time
Amputation Regular part time
Broken bone Seasonal
Bruise Temporary
Burn (heat)
Burn (chemical) Months with this employer:
Concussion (to the head)
Crushing Injury Months doing this job:
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other ____________
STEP 2: Describe the incident

Exact location of the incident: Exact time:
What part of employee’s workday?
Entering or leaving work Doing normal work activities During meal period During break Working overtime Other ____________
Names of witnesses (if any):
Number of attachments:
Written witness statements Photographs Maps/drawings:
What personal protective equipment was being used (if any)?
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.
Description continued on attached sheets:
Page 21
STEP 3: Why did the incident happen?

Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply)
Inadequate guard Operating without permission
Unguarded hazard Operating at unsafe speed
Safety device is defective Servicing equipment that has power to it
Tool or equipment defective Making a safety device inoperative
Workstation layout is hazardous Using defective equipment
Unsafe lighting Using equipment in an unapproved way
Unsafe ventilation Unsafe lifting
Lack of needed personal protective equipment Taking an unsafe position or posture
Lack of appropriate equipment/tools Distraction, teasing, horseplay
Unsafe clothing Failure to wear personal protective equipment
No training or insufficient training Failure to use the available equipment/tools
Other ____________ Other ____________
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more quickly” or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or
acts? Yes No If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? Yes No
Have there been similar incidents or near misses prior to this one? Yes No
STEP 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?
Stop this activity Guard the hazard Train the employee(s) Train the supervisor(s)
Redesign task steps Redesign work station Write a new policy/rule Enforce existing policy
Routinely inspect for the hazard Personal Protective Equipment Other ____________
What should be (or has been) done to carry out the suggestion(s) checked above?
Description continued on attached sheets:
STEP 5: Who completed and reviewed this form? (Please Print)
Written by: Title:
Department: Date:
Names of investigation team members:
Reviewed by: Title:
Date:
Page 22
Authorization for the Release of Medical Information
Employee Name: Date of Injury:
Employer Name: Date of Birth:
I hereby authorize the insurance carrier, their representative or bearer, to review, inspect, copy and/or
photograph any and all of the following documents:
1. Any and all medical records, including but not limited to: office and hospital records, laboratory results, diagnostic reports and
films, psychiatric records, medical correspondences, doctor's and nurse's notes and medical histories relevant to my workers'
compensation claim. I also hereby give permission to the insurance company representatives to contact the attending
physicians involved in the treatment of all related conditions.
2. All employment and human resource information including but not limited to: hiring and employment records, payroll and
income statements, documentation related to this or any other relevant injury and any other information pertinent to providing
benefits and services necessary for the completion of this claim.
The released information is required for the following reasons:
1. To provide for adequate preparation, investigation, evaluation, review and discovery of a claim for workers compensation
benefits. Specifically, to determine the causation and the nature and extent of any possible preexisting, concurrent or
aggravating medical conditions with potential medical, legal or factual implications in the this work-related injury or injuries.
2. To provide the treating physician, consultant or evaluator with medical information necessary to provide you with the best
possible medical care and medical advice.
3. To facilitate recovery of all benefits paid toward your workers compensation claim from any third party responsible for this
injury.
4. To ensure that you are accurately compensated for any amount of lost wages, time or resources while undergoing evaluation,
treatment and recovery for this injury.
5. To obtain any information necessary to appropriately determine further actions as a result of the injury or condition and to
prevent further issues for you and other employees.
This consent and authorization is effective immediately, and is subject to revocation by the undersigned at any time except to the
extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate on conclusion of the claim without
express revocation.
A copy or fax is as valid as the original.
(names, addresses. and phone numbers of providers)
I have read this authorization and fully understand its entire contents. I have asked questions about anything that was not clear to
me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this authorization upon
my request.
Signed: Date:
Page 23
Auto Accident Report Form

When an accident occurs:
First Steps Do Not Say While Still At The Scene

• Remain calm • It’s all my fault (even if it is). • Get as much information as
• Get to a safe place • My insurance will pay for possible on this report.
• Check for injuries everything. • Take Pictures
• Administer First Aid • It’s OK, I have full coverage. • When the police come, cooperate
• Call police/EMT and tell them what you know.
Accident Details
Day/Date/Time AM/PM
Weather/Road Conditions
Location of Accident
Accident Details
Damage Descriptions
Your Vehicle Other Vehicle
Towing Company Name & Phone Towing Company Name & Phone
Other Driver/Vehicle Information
Owner's Name:
Owner's Address:
Owner's Phone:
Vehicle Make:
Vehicle Model & Year:
Vehicle Color:
License Plate Number
Insurance Company:
Agent Name & Phone:
Other Driver’s Name:
Other Driver’s Address:
Other Driver’s Phone:
Page 24
Passengers/Injuries
Your Vehicle Other Vehicle
# Passengers # Passengers
Police Information
Officer Name:
Department:
Phone:
Badge Number:
Other Info:
Witness Information
Name: Name:
Address: Address:
Home Phone: Home Phone:
Work Phone: Work Phone:
Sketch The Accident Scene
Page 25
General Liability Incident Report Form

INSTRUCTIONS
If a person is injured or property of others is damaged (or alleged) as a result of our organization and operations, whether negligent or not,
report the claim directly to the insurance carrier. Keep your answers brief and to the point.
*** Do not use this form for Auto Liability Claims ***
Time is of the essence. Do not delay reporting the claim because you do not have all the information regarding the accident. Any additional
information can be provided at a later date. Use multiple sheets for more than one Claimant.
ACCIDENT INFORMATION – GENERAL LIABILITY
Location Involved and Location

Code:
Date of the Incident: Incident Time:
Incident Location: City and Country:
Description of the Incident:
Police Authorities Contacted: If yes, Accident Report number:
CLAIMANT INFORMATION
Name & Address of Claimant: Home Telephone No./Work Telephone No.:
Injured Party Date of Birth: Social Security Number:
INJURY INFORMATION
Brief Description of the Claimant’s Injury:
Fatality: Yes No
What initial treatment was given? By whom?
Was hospital treatment needed? Which hospital?
WITNESS INFORMATION
Were there any witnesses? If so, their name, address and phone no.
PROPERTY DAMAGE TO OTHERS INFORMATION

Claimant’s property involved: Where is the property located now?
Damage to Claimant’s property: Repair Estimate:
Comments:
Your Name: Phone Number:
Page 26
Property Damage Report Form
Reported by: Dept.: Date:
Date of Incident: Time of Incident: a.m. p.m.
Location of Incident and Location Code:
Was Police Department Notified? Yes No Was Fire Department Notified? Yes No
INCIDENT REPORT
Injury to Person
Damage to Property
Other (describe)
Name of Party Phone
Address (include complete address, with street address, city, state and zip code)
Driver’s License No.
Briefly describe what

happened:
Did party indicate intent to file a claim against agency? Yes No
WITNESS INFORMATION
Name: Address: Phone:
INCIDENT ACTIVITY LOG
Date Comments Diary/Activity
Page 27
Inland Marine/Cargo Transit Incident Report

Complete for all Cargo losses (Ocean Marine, Inland Marine, and Truck Cargo)
Prepared by:
Location Address:
Prepared by: Title: Phone:

AM
Incident Date: Time: PM Weather Conditions:
Who Reported Incident to You? Date Reported:
Point of Contact for Insurance Company:
Phone: Fax: E-mail:
INCIDENT
Shipment en route from: to:
Description of Cargo:
Description of Incident:
Damages (be specific):
Is cause of damage known at this time?
Law Enforcement Agency (if any): Report #:
DOCUMENTATION:
Please attach the following documents (if readily available) to this report:
• Bill of Lading (front and back sides)

• Packing Lists
• Inventories
• Customs Documents
• Delivery Receipts (make note of any damages or shortages on the receipt before signing for delivery)
• Inspection or survey reports
• Purchase Invoices
• Sales Invoices
• Any correspondence with / from shippers, agents, etc.
Do not delay in reporting this loss if the information outlined above is not readily available. Complete this report as soon
as you are made aware of the loss and forward it to:
Report completed by: Date:
Page 28

Claims Reporting Reference Guide

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© 2019 Arthur J. Gallagher & Co.

• Be sure to complete an Employer’s First Notice of Injury.

• Correct hazards immediately.

Auto Physical Damage

Hired Automobile Liability

Nonowned Automobile Liability

• Determine if there are injuries and if necessary, seek medical attention.

• If possible, photograph damage to any vehicles involved.

• Report all collected information to your immediate supervisor.

• Determine if there are injuries and if necessary, seek medical attention.

• If needed, file and obtain a police report.

• Do not assume responsibility for any medical bills or property damage.

• Retain damaged property for inspection by insurance company adjuster.

• Keep area safe after a loss.

• Obtain detailed repair estimates and provide them to the carrier.

• If needed, file and obtain a police report.

Boiler, Machinery & Equipment Breakdown

• Retain damaged property for inspection by insurance company adjuster.

• Obtain detailed estimates for repairs.

Professional Liability/Errors and Omissions Coverage

DUTY TO DEFEND POLICY:

BREACH RESPONSE NOTIFICATION REQUIREMENTS

INITIAL COVERAGE EVALUATION

Employment Practices Liability

DUTY TO DEFEND POLICY:

Directors & Officers Liability Coverage

DUTY TO DEFEND V. NON DUTY TO DEFEND POLICY:

• Theft (not all theft triggers coverage).

• Forgery (not all forgeries trigger coverage).

• Loss due to robbery or attempted robbery.

• Third-party money order and counterfeit currency fraud.

• Theft from a named executive’s personal account.

• ERISA fiduciary bonds (different than Fiduciary Liability coverage).

• Late notice may jeopardize coverage.

Fiduciary Liability Coverage

DUTY TO DEFEND POLICY:

Avoid Coverage Disputes

NOTICE IMPLICATIONS OF “CLAIMS-MADE” POLICIES

WHAT CONSTITUTES A “CLAIM?”

Directors and Officers Liability Employment Practices Liability

“Claim” means: “Claim” means:

NOTIFYING THE CARRIER OF A CLAIM

Accident Investigation & Problem Solving Guide

“Person Breakdowns” should be given as much, if not more,

Incident Investigation Tips

EMP — Common in Every Operation

Using the Six “Ws

Employer’s First Report of Injury Form

Employer’s Mailing Address Employer’s E-mail Address

Nature of Business or Service SIC Code

Name of Workers Compensation Carrier/Administrator Policy/Contract # Self-Insured?

Employee’s Mailing Address Employee’s E-mail Address

Gender Marital Status # of Dependents Employee’s Average Weekly Wages

What was the employee doing when the accident occurred?

How did the accident occur?

What object or substance, if any, directly harmed the employee?

Name and address of physician/healthcare professional.

Employee’s Report of Injury Form