ABCDEFGHIJKLMNOPQRSTUVWXYZ
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LIABILITY ACCIDENT NOTICE
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NON-AUTOMOBILE
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POLICY NUMBER:CLAIM NUMBER:
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(1)NAMEPHONE
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INSUREDUNIVERSIDAD DE PUERTO RICO
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CAMPUS NAME & ADDRESS
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PREMISSES
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(2)
DATE & TIME OF ACCIDENT
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TIME & PLACEAM:PM:
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LOCATION
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(3)NAMEAGE
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INJURED PERSON
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ADDRESSCEL PHONERES. PHONE
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RELATIONSHIP TO INSURED
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EMPLOYED BY
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WHAT WAS INJURED DOING WHEN HURT?
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(4)
NATURE & EXTENT OF INJURY
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THE INJURY
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WHERE WAS INJURED TAKEN AFTER ACCIDENT?
NAME OF DOCTOR
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WHY WAS INJURED ON PREMISES?
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PROBABLE DISABILITY
HAS INJURED RESUMED WORK?
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 ( ) YES ( ) NO
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(5)
OWNER AND ADDRESS
PHONE
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PROPERTY DAMAGE
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LIST DAMAGEVALUE
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(6)NAMEPHONEOTHER PHONE
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WITNESSES
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ADDRESS
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(7)
DATE. LOCATION OR NAME OF POLICE AUTHORITY TO WHOM ACCIDENT WS REPORTED
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DESCRIPTION OF ACCIDENT
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DATECLAIMANTUPR REPRESENTATIVE OFFICER (name/title)
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