SPECIALTY CLAIMS SERVICES INC. P.O. BOX 381136, CLINTON TOWNSHIP, MI 48038
PHONE: (586) 877-855-8614 FAX: (586) 226-2217
Completion of this form does not imply that your claim will be paid or that the School District is liable for your damages.
/ CLAIMANT NAME: DOB: SS#:ADDRESS: CITY:
STATE: ZIP CODE: PHONE: (HOME): (WORK):
SCHOOL DISTRICT:
DATE & TIME OF ACCIDENT/INCIDENT:
LOCATION OF ACCIDENT/INCIDENT:
POLICE NOTIFICATION? YES NO COMPLAINT NUMBER:
DESCRIPTION OF ACCIDENT/INCIDENT:
WITNESSES: YES NO (If so, provide name, address, and telephone numbers on back of this form.)
/ INJURED? YES NO (If yes, please describe):
ARE YOU TREATING NOW? YES NO NAME AND LOCATION OF MEDICAL FACILITY:
ANY LOST TIME FROM WORK/SCHOOL?: YES NO (If yes, how long?):
NAME, ADDRESS, PHONE NUMBER OF EMPLOYER:
DATE RETURNING TO WORK:
MEDICAL INSURANCE COVERAGE: YES: NO: CARRIER:
HAS CLAIM BEEN REPORTED TO YOUR CARRIER? YES: NO:
/ 1
AUTOMOBILE INVOLVED: MAKE: MODEL: YEAR:
DESCRIBE DAMAGE:
ATTACH (2) ESTIMATES: SHOP #1 EST. $ SHOP #2 EST. $
AUTO INSURANCE INFORMATION (Name, Address, Phone Number of Ins. Co.):
AGENT’S NAME: POLICY #:
COLLISION COVERAGE: YES: NO: DEDUCTIBLE $
COMPREHENSIVE COVERAGE: YES: NO: DEDUCTIBLE $
MED PAY COVERAGE: YES: NO: AMOUNT: $
HAS CLAIM BEEN REPORTED TO YOUR CARRIER?: YES: NO:
/ DESCRIBE DAMAGE TO PROPERTY OTHER THAN AUTO:
ATTACH (2) ESTIMATES: EST. #1 $ EST. #2 $
HOMEOWNER’S COVERAGE: YES NO DEDUCTIBLE $
HOMEOWNER’S INSURANCE INFORMATION (Name, Address, Phone Number of Ins. Co.):
POLICY #:
:
(Please print name of person completing form) (Relationship to Claimant)
SIGNATURE (Required) DATE
NOTE: A copy of your insurance declarations page (showing policy dates and coverages pertinent to accident date) and police report (if applicable) are required to process your claim. Failure to supply any information that is requested on this form will cause delay in the processing of your claim.