Government Entities Mutual, Inc.

GEM Reinsurance or Accident Loss Notice

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Section A: Member Data
GEM Member Name
Member's Adjuster Name
... Email Adress

Section B: Coverage Data
Type of Coverage Liability | Workers' Compensation | Auto Physical Damage | Property
If Liability, Type
If Property, Police or Fire Dept. Reported To
If Property, Probable Amt. entire loss (if known)
If Property, Kind of Loss

Section C: Claims Data
GEM Member Claim No.
Suit Status Yes | No
Name of Pool Member where Claim Filed
Date of Loss/Occurrence (MM/DD/YYYY)
Loss Location
Date Claim Filed with GEM Member (MM/DD/YYYY)

Section D: Claimant Data
Claimant Name (if a person, enter "Last, First MI")
Injury/Damages
Date of Birth (MM/DD/YYYY)
Gender
Marital Status
Dependent 1 Name
... Date of Birth (MM/DD/YYYY)
Dependent 2 Name
... Date of Birth (MM/DD/YYYY)
Dependent 3 Name
... Date of Birth (MM/DD/YYYY)

Section E: Incurred Loss and Damage
Valued as of (MM/DD/YYYY)
Outstanding ReservesPaid To DateRecoveries/Salvage
(enter positive numbers to be
subtracted from paid amounts)
Total Incurred Losses
Indemnity/Loss
Medical
Legal
Expense
Total

Section F: Description of Loss
Description of Loss

Section G: Remarks/Other Insurance
Remarks/Other Insurance
Verification