Cardinal Point Claim Report

Date:

mm/dd/yyyy

Policy Type:

Audit Assurance	Brand Protection	Contractor Default
Deductible Reimbursement	Business Interruption	Dispute Resolution
Employer Liability Int.	Food Borne Illness	Key Employee Accident & Illness
Political Risk	Professional Liability	Recall Assurance
Supply Chain Int.	Third Party Int.	Data Breach
Credit Default	Directors & Officers	Representations & Warranties
Stock Deterioration	Livestock Death Loss

Name of Insured:

Policy #:

Insured's Mailing Address:

Street, City, State Zip

Phone Number:

Email Address:

Contact

Name of Contact:

Contact's Mailing Address:

Street, City, State Zip

Phone Number:

Mobile Number:

Email Address:

Date of Occurrance / Claim:

mm/dd/yyyy

Location of Occurrance / Claim:

Description of Occurrance / Claim:

Estimated Financial Loss:

Please attach proof of loss:

Additional Parties Invovled

Are there additional parties invovled?

YesNo

Business Name:

Contact Name:

Address:

Street, City, State Zip

Phone Number::

Mobile Number:

Email Address:

Are there more additional parties involved?

YesNo

Please list additional parties invovled:

Mitigation Expenses

Has a Company / Firm been contracted to mitigate damages?

YesNo

Company / Firm Name:

Contact Name:

Phone Number:

Email Address:

Date Contracted:

mm/dd/yyyy

Services Provided: