LIABILITY CLAIM REPORTING FORM

INSURANCE  PROGRAM FOR FOSTER PARENTS 

(USE THIS FORM IF A CLAIM POTENTIALLY INSURED BY THIS POLICY IS BEING MADE AGAINST YOU.)

1.	Foster Parent _______________________________________________________________________

2.	Street Address __________________________________________________________________________________________

City ______________________________ State ________ Zip ______________ Telephone# ___________________________

3.	Foster Parent License # _________________________________ 

4.	Name of Foster Child ______________________________________________________________________
	
Foster Child Date of Birth ________________________________________             (OR) Age __________          Sex _______

5.	SPECIFIC date and time of incident _______________________________________________________________________

6.	Where did incident take place?  ____________________________________________________________________________

7.	Description of incident ___________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________
8.	PERSONAL INJURY SECTION 
  	(Complete this section only if a claim for INJURY is being made AGAINST you or the person named in number 4)

Full Name of Injured Party _______________________________________________Telephone # _______________________

Address ________________________________________________________________________________________________

Age _________  Sex __________  Occupation _________________________________________________________________

Description of Injury _____________________________________________________________________________________

Physician’s Name or Medical Facility _______________________________________________________________________

9.	PROPERTY DAMAGE SECTION
	(Complete this section only if a claim for PROPERTY DAMAGE is being made AGAINST you or the person named in number 4)

Name ______________________________________________________ Telephone # ________________________________

Address _______________________________________________________________________________________________

Description of Damaged Property ___________________________________________________________________________

Estimated Amount of Damage _______________________________________________________________________________

Where can damages be seen? _______________________________________________________________________________

10.	WITNESS SECTION (LIST ANY WITNESSES TO THE INCIDENT)

Name ______________________________________________________ Telephone # ________________________________

Address _______________________________________________________________________________________________

11.	Other remarks or comments as to fault _______________________________________________________________________

12.	Has loss been reported to your insurance company? _____________________________________________________________

If yes, name and phone # of person reported to _________________________________________________________________

	______________________________________________________		______________________________________
				Signature							       Date
PLEASE COMPLETE AND MAIL THIS FORM IMMEDIATELY TO:
RISK MANAGEMENT DIVISION
85 STATE HOUSE STATION

Rev. 12/12

O:\WPFS\CLAIMS\CLAIM FORMS\FOSTER PARENT LIABILITY CLAIM REPORTING FORM.DOC   

AUGUSTA, MAINE  04333

				    		          1-800-525-1252 or 287-3351