1. Basic Information

Your Name:
Company Name:
Contact Information:
Policy Number:
Policy Details:
Point of Contact:

2. Incident Details

Project or Location:
Work Performed Date:
Type of Work:
Nature of Faulty Workmanship:
Date Issue First Noticed:
Total Cost of Materials:
Do You Have Receipts?:YesNo
Total Cost of Labor:
Flaws in Materials Expected?:YesNo
Project Completed or Ongoing?:CompletedOngoing
Who Did the Work?:
Current License to Perform Work?:YesNo
Materials Damaged?:YesNo
Describe Material Damage:
Materials Defective?:YesNo
Date Defects Identified:

3. Coverage Period and Location

Workmanship in the US?:YesNo
Work Start Date:

4. Notification and Awareness

Date Issue First Known:
Authorized Personnel Aware Before Claim?:YesNo
Submitting Claim in Reporting Period?:YesNo

5. Contractual and Financial Details

Estimated Project Cost (over $500?):YesNo
Written Contract Signed Before Work?:YesNo
Amount of Damages Claimed:

6. Legal and Arbitration Information

Lawsuit Filed?:YesNo
Subject to Arbitration/Mediation?:YesNo
Do You Have Legal Representation?:YesNo

7. Documentation

Upload Relevant Documents:
Additional Information: