Property & Liability Claim Reporting Form

File a Claim

The following errors were found:

Incident Details

Member Name*

Your Name*

Date Incident Occured*

Your Phone Number*

Brief Description of Incident*

Claim

Did the incident involve damage to a vehicle or property or other?

Vehicle

Was this a member owned vehicle or a citizen owned vehicle or both?

Was the damage due to collision with an object?

e.g. Car, tree, or post.

The following errors were found:

Date of Incident:

Incident Description:

Member Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

The following errors were found:

Date of Incident:

Incident Description:

Member Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Was there injury to a person?

The following errors were found:

Date of Incident:

Incident Description:

Citizen Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Injured Claimant

First Name*

Middle Name

Last Name*

Address*

City*

State*

Zip*

Phone

Type

SSN

Gender

Date of Birth

Description of Injury*

Was the person listed above driving the vehicle at the time of the incident?

Citizen Driver

First Name

Last Name

Address

City

State

Zip

Phone

Type

Were there any witnesses to the incident?

Witness (form #9)

First Name

Last Name

Address

City

State

Zip

Phone

Type

Were there any additional witnesses?

Please list contact information for

Additional Witnesses

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

The following errors were found:

Date of Incident:

Incident Description:

Citizen Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Citizen Claimant

First Name

Last Name

Address

City

State

Zip

Phone

Type

Was the person listed above driving the vehicle at the time of the incident?

Citizen Driver

First Name

Last Name

Address

City

State

Zip

Phone

Type

Were there any witnesses to the incident?

Witness (form #9)

First Name

Last Name

Address

City

State

Zip

Phone

Type

Were there any additional witnesses?

Please list contact information for

Additional Witnesses

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Was anyone injured in the non-member vehicle?

The following errors were found:

Date of Incident:

Incident Description:

Citizen Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Citizen Claimant

First Name

Last Name

Address

City

State

Zip

Phone

Type

Member Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

The following errors were found:

Date of Incident:

Incident Description:

Citizen Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Citizen Injured

Injured Claimant

First Name*

Middle Name

Last Name*

Address*

City*

State*

Zip*

Phone

Type

SSN

Gender

Date of Birth

Description of Injury*

Member Vehicle

Vehicle Make

Vehicle Model

Vehicle Year Built

VIN

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Property

Was there injury to a person?

The following errors were found:

Date of Incident:

Incident Description:

Injured Claimant

First Name*

Middle Name

Last Name*

Address*

City*

State*

Zip*

Phone

Type

SSN

Gender

Date of Birth

Description of Injury*

Property Location

Address of Incident

City

State

Zip

Contact Name

Contact Phone Number

Describe what happened to property (e.g. Tree fell on roof)*

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Was this a member owned property or a citizen owned property?

The following errors were found:

Date of Incident:

Incident Description:

Property Location

Address of Incident

City

State

Zip

Contact Name

Contact Phone Number

Describe what happened to property (e.g. Tree fell on roof)*

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

The following errors were found:

Date of Incident:

Incident Description:

Property Location

Address of Incident

City

State

Zip

Contact Name

Contact Phone Number

Describe what happened to property (e.g. Tree fell on roof)*

Citizen Claimant

First Name

Last Name

Address

City

State

Zip

Phone

Type

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Other

The following errors were found:

Date of Incident:

Incident Description:

Injured Claimant

First Name*

Middle Name

Last Name*

Address*

City*

State*

Zip*

Phone

Type

SSN

Gender

Date of Birth

Description of Injury*

Property Location

Address of Incident

City

State

Zip

Contact Name

Contact Phone Number

Describe what happened to property (e.g. Tree fell on roof)*

Full Details of Event

Detailed description of event, persons involved

Attachments

No attachments.

Upload photos, memos, police reports or other documents that will assist us in handling the claim.

Start Over

Claim has been entered

Your claim has been submitted and is pending review.

Claim #

If you have any questions please contact the CIS claims department at 503-763-3875 or claimspl@cisoregon.org.

Error saving claim

There was a problem saving your claim.

Please contact the CIS claims department at 503-763-3875 or claimspl@cisoregon.org.

Property & Liability

Property & Liability Claim Reporting Form

File Selection / Upload

Incident Details

Q.C. Test

Claim

Vehicle

Member Vehicle

Full Details of Event

Member Vehicle

Full Details of Event

Citizen Vehicle

Injured Claimant

Citizen Driver

Witness (form #9)

Full Details of Event

Citizen Vehicle

Citizen Claimant

Citizen Driver

Witness (form #9)

Full Details of Event

Citizen Vehicle

Citizen Claimant

Member Vehicle

Full Details of Event

Citizen Vehicle

Injured Claimant

Member Vehicle

Full Details of Event

Property

Injured Claimant

Property Location

Full Details of Event

Property Location

Full Details of Event

Property Location

Citizen Claimant

Full Details of Event

Other

Injured Claimant

Property Location

Full Details of Event

Claim has been entered

Error saving claim

Main

Claims

Pre-Loss Employment Risk Management