Multinational Commercial Liability Loss Notice
NOTICE OF LOSS
Completion of this form and forwarding any requested documents will expedite the handling of your claims
* indicates required field
I. Preparer Information

Your Name: Email Address:*
Phone Number: Date Prepared:
* Required in order to send confirmation that your loss has been received.

II. Insured Information

Insured Name: Policy Number:
Effective Date:  To 
Local Policy Number:
Insured Contact Name: Contact Phone:
Contact Email Address: Contact Fax:
Country Reporting From:

III. Loss Information

Date of Loss: Loss Location:
Type of Loss: Product Premise Other
If Other, please explain:
Loss Description:

IV. Claimant Information

Claimant Name: Claimant Phone:
Address:
Age: Male Female
Occupation:
If Represented, Attorney's Name and Contact Details:

V. Producer Information

Broker/Agent Name: Contact Person:
Telephone Number: Email Address:

VI. E-Mail Instructions:

All receipts, police reports, and/or other relevant documents/photographs should be faxed without delay using the fax number shown below. Or, if available in electronic format, please click here to attach to an e-mail.  Please include the Insured Name, Policy Number, and Date of Loss in the Email.  Retain all originals as they may be requested. 

Once you have completed this form and e-mailed electronic documentation, press the 'Submit Loss For Review' button.

Fax Numbers:      
From US and Canada: 1-877-200-5202     
From All Other Countries: See Dialing Instructions  


 
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We would appreciate feedback. Please contact us by e-mail at MCU@chubb.com