Personal Liability Claim Form

"Guiding Your Claims Process"

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At the Oberman Companies, we know that filing a claim is an unexpected event that can be stressful. Our role is to help guide you through the claims process. To get started, we need some details to expedite the service.

NOTE: Report claims or notice of potential claims as soon as possible. Please DO NOT wait to report a claim because you do not have ALL the loss details. Additional information can be provided to us at a later date.

Contact Info

Your Name(Required)

First Last

How Can We Reach You?

Please Provide Your Contact Information

Your Email Address(Required)

Preferred Contact Method(Required)

Your Phone(Required)

Secondary Contact Name (e.g. Superintendent/Resident Manager, if applicable)

Secondary Phone

Secondary Email

Incident Report

Please Fill Out All Requested Details

For Record Purposes Only At This Time?(Required)

Yes

Unsure At The Moment

Date of Loss(Required)

MM slash DD slash YYYY

Time of Loss (if known)

Hours

Minutes

AM/PM

Type of Loss (.g. liability-bodily injury, property damage, or personal injury)(Required)

Location of Loss(Required)

Loss Description(Required)

Were the Authorities Called (e.g. Fire, Police, etc.)(Required)

Yes

Name of Precinct, Town/City/State That Responded(Required)

Legal

Claimant Name(Required)

First Last

Claimant's Attorney

First Last

Does The Claim Involve Bodily Injury?(Required)

Yes

Did The Claimant Indicate That They Would Seek Medical Attention?(Required)

Yes

Was An Ambulance Called?(Required)

Yes

Did The Claimant Go to a Hospital or Urgent Care Facility?(Required)

Yes

Name of Medical Facility, If Known

Could This Be a New York State Labor Law Claim?(Required)

Yes

Maybe

Documentation

Was The Accident Location Inspected by an Employee?(Required)

Yes

Were Photos or Video Taken of the Alleged Incident?(Required)

Yes

Upload Photos and Videos If Possible

Drop files here or

Max. file size: 98 MB.

(Note: You must have one or both before making both temporary emergency repairs and/or permanent repairs.) *If you are transmitting photos/video in a file sharing software, please make sure Oberman and/or the carrier can open the software and meets size requirements. If you are saving video, please make a backup copy.

Additional Details

Every insurance policy has a "Duties in the Event of Loss or Damage" section. For simplicity's sake, we have included a generic one from Insurance Services Office (I.S.O.) Your carrier’s duties section may vary slightly.

SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS

2. Duties In The Event Of Occurrence, Offense, Claim Or Suit

a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, notice should include:

(1) How, when and where the "occurrence" or offense took place;

(2) The names and addresses of any injured persons and witnesses; and

(3) The nature and location of any injury or damage arising out of the "occurrence" or offense.

b. If a claim is made or "suit" is brought against any insured, you must:

(1) Immediately record the specifics of the claim or "suit" and the date received; and

(2) Notify us as soon as practicable. You must see to it that we receive written notice of the claim or "suit" as soon as practicable.

c. You and any other involved insured must:

(1) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the claim or "suit";

(2) Authorize us to obtain records and other information;

(3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit"; and

(4) Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the insured because of injury or damage to which this insurance may also apply.

d. No insured will, except at that insured's own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent.