APEX EXCESS & SURPLUS
R&Q Quest (SAC) Limited
F. B. Perry Building | 40 Church Street
PO Box HM2062
Hamilton HM HX, Bermuda

For assistance please email: info@apexexcessandsurplus.com or call 214-714-7343

NOTICE OF OCCURRENCE / CLAIM

 

Date of Loss (Start and End Date; if loss occurrence is ongoing please only list the claim start date): 

Apex Certificate Number: 


PART 1: Certificate Holder

Name of Business Insured:    

Mailing Address:   City:   State:   Zip:  

Primary Phone:     Work Cell          Secondary Phone: Work Cell


Part 2: Contact

Primary Email:         Secondary Email:  

Name of Contact Responsible for Claim Submission:   Email (if not listed above): 

Name of Contact Responsible for Claim Handling:   Email (if not listed above): 


Part 3: Loss Occurrence

1. Covered Loss Line Description Under Which Claim is Being Made: 

2. Loss Amount Claimed:  

3. Description of Occurrence (in the space provided below, please provide a full description that includes all information relevant to the occurrence and subsequent claim being made):

 


Part 4: Attachments

Please attach all documentation pertaining to the claim that supports the claimed amount and how the total claim amount was determined.

  • If property damage: original cost new of the items and the basis (Cost of Repair, Actual Cash Value, Replacement Cost, Market Value) of what is being claimed.
  • If loss of profits or earnings, method of determination with supporting documentation, e.g. Financial Statements year over previous year adjusted for increased sales or unrelated loss of business, etc. ​​​​​​
  • If expense reimbursement: documentation of loss event and receipts or invoices along with proof of payment.  


I warrant the information on this Claim Form is true and correct and that all representations on this form are accurate. I understand that misstatements may void the validity of this loss:

Name:  Authorized Individual Name: