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 L

c EINNATI SERVICE CENTER
”WAN“ ST. P¥JL FJRE AND MARINE INS. co.
Q9 ST. P UL I‘ERCURY INSURANCE co.

GERALD (JERRY) H. FREESE
REPRESENTATIVE
LOSS PREVENTION-AUDIT DEPARTMENT
SUITE 620 .

HOLIDAY PARK TOWER

644 LINN STREET
PHONE: 241-1980 CINCINNATI, OHIO 45203

 I ‘ 1’ I} l / I; e
. k. ._ J 1.: x t ’ . . . . ..
NAME OF COMPANY JJJ” ELI : 6'1 Wo- U5 .T. 1' I x ’ -« ’ USE REVERSE SIDE FOR
I REPORTING PROPERTY LOSSES.
CASE NO.
POLICY NUMBER POLICY DATES .7 NAME & ADDRESS OF AGENT 0R BROKER
[1 C A “II My ' .. i: . ' . Cw.
COVERAGE LIABILITY MED. PAYMENTS ELEVATOR PRODUCTS co RACTUAL OTHER (SPECIFY)
DATA w
I:
E
To BE 3
COMPLETED
BY AGENT
(1) NAME . BUS. PHONE RES. PHONE
’ I
\ L. . ...n .. (_.,
n . ML OH. . ,'.} I s T. J Lu”; .3 . T I)! 64.23 431%
INSURED ADDRESS '
I, I ELL (J.JP 2.:-W". C,
LOCATION OF INSURED PREMISES ( SAME AS ABOVE
J 5
I ) ‘I f f; .‘. LU Hm .v’ ’3 ECU 1' f. .». x, ‘6 ,T.“:UZJEs
(2) DATE 8. TIME OF ACCIDENT ‘
7v? 7" 7 ( ) A.M. /Z.’30(2‘\) P.M.
TIME & PLACE LOCATION
{A1 {ELIOT 6e. T {a PIP C, J //‘/‘s‘1'¥"ﬂ-T}€A .70 .
(3) NAME V. AGE
"'5 ‘.. r14... 1w ’
AU. In; .35‘ 2 ‘~ I h T‘ M 1: H ID
INJURED ADDRESS BUS. PHONE RES. PHONE
PER . . /
5°" WEEKSQLHm; < , ,,QCX’IbY
OCCUPATION ‘ RELATIONSHIP To INSURED
"I I J..: F; UT”
EMPLOYED BY:
\
WHAT WAS INJURED DOING WHEN HURT? [2.“ g} g; If}, Y 1:: : 1 J., .. 3;. 0 LL 3 l S t: {is IT :.. ‘ a WWI/4 ‘ .«J‘ In: if; .
5:}?! W i i- 35%? :3 22.3" "' L w “‘.'I I! "II; '7’/L) -: .>’ ’ I :I‘ w. .’.. I “Ti/71.)“, 'T 4““???1L71.
NATURE & EXTENT OF INJURY ‘
(4) v I . L A ' ,. . I r. . 4
x " ' z :5 he " CPS - O Si" L lid '4’ It‘s" ‘,.!H' IL (I 3 Nil» 1,361 J‘E‘TE‘W: 34 ‘IIIROUUJ. Se! rm; .
THE INJURY WHEREJWAS INJURED TAKEN AFTER ACCIDENT?7~A5 fl"; :31; :vrr»: 5;; ;;;-1‘- {_., ;- M.,;zg‘“ 3 WGKSUAME 0F DOCTOR i I
6 E \ll”; JIM) 'Z‘GIIGK 5"“: Calm-J V) 9 “'5: .II/Wm;- D. . QIMH‘UI; (HIM!
. WHY WAS INJURED ON PREMISES? U ,
, I ,
Trig“ "Rf? ‘Z.*IH:.. ,3;
PROBABLEmSABILJTY k, HAS INJURED RESUMED WORK?
I Hi? ( ) YES ( ) NO E/(f/‘iféé‘v‘j ié‘I‘ML, X’ZZQ-Z?
(5) OWNER ADDRESS BUS. PHONE RES. PHONE
PROPERTY ~ _, , '
DAMAGE LIST DAMAGE - ' ' ‘ ESTIMATED COST OF REPAIR
(6) NAME ADDRESS BUS. PHONE ' RES. PHONE ;
.A \.
:0 .II r‘w I.“ . M' .
VIPER L p.r‘el,.«beL£_. UJTéfKSEUdQ . MOE?’ »'3 .21-r” TA
WITNESSES ’
Jim/Is A’ARIS Du T/ééLwavﬁéh IR. MM.
(7) . .- . ‘ . : .
6.5;“??? A A S m .‘Eé T»: um (:5 it an. V’./.‘L-{12’J'ri r? (PM ME?" 1-:: ~... m ' :5 VS»
DESCRIPTION x.‘ ' .
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ACCIDENT ’4: "J - I“ ' . ‘ “‘ I’ ' ’
~ .~ . . ... _ 7\ ‘.' ,. ‘__I;, ,., '
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DATE. LOCATION & BADGE NO. OR’NAME OF POLICE AUTHORITY Td WHOM ACCIDENT WAS RE-e- D. ’
' 4 DA! \ T’H 5W3“: I ‘er .5 . . ' I 3:34: "‘.3,“ A m. L15 D " 3 533“”?!
‘ I” : 1T . » ./ , . .
‘1»/3 r 73 w/AZZLIZETBM 340574425
DATE SIGNATURE or AGENT 0R BROKER SIGNATURE OF INSURED
RECOMMENDED BY THE AMERICAN INSURANCE ASSOCIATION 8-65

 .. NAMEOFCOMPANY NOTICE OF LOSS
: FIRE, ALLIED LINES, HOMEOWNERS, UTHER MULTl-PERIL POLICIES
use REVERSE SIDE FOR REPORTING LIABILITY I
2. AGENCY NAME, STREET ADDRESS (RUBBER STAMP OR TYPE) CLA M3
7. POLICY PREFIX 8: NUMBER 8. POLICY PERIOD (FROM, TO)
9. DATE OF LOSS 10. KIND OF LOSS (Fire. Wind., Expl., etc.)
‘1 11. PROBABLE AMT. ENTIRE LOSS 12. PROB. AMT. LOSS THIS POLICY
3. INSURED $ $
13. WAS CREDIT GIVEN FOR EXISTING INSURANCE?
4. PROPERTY ADDRESS PHONE NO. CI YES I__I ”0 CI “063- CI CONTENTS
14. MORTGAGEE
5. MAIL ADDRESS (if different) PHONE NO.
6. LOSS LOCATION IF DIFFERENT THAN PROPERTY ADDRESS
FIRE, ALLIED LINES AND MULTI-PERIL POLICIES Complete below only lfem(s) involved in Loss as described by this Policy
Amount Amount Amount Percent of Coins. . .
W Building Other Items Applicable *Coverage and/or Description Of Property Insured
15. SUBJECT TO FORM NUMBERS: (INSERT FORM NUMBERS AND EDITION DATES)
16 Deductible Deductible Deductible,
' Windstorm and Hail Other Perils Misc. (Explain)
$ $ $
HOMEOWNERS POLICIES Complete below Coverages A, B, C, D and Additional Coverages, except liability
COVERAGE A COVERAGE B m COVERAGE O — DESCRIBE ADDITIONAL COVERAGES PROVIDED
Appur‘tenant Unscheduled Additional $ on
Dwelling Private Personal Living $ on
Structures Property Expenses .
$ on
$ on
$ $ $ $ $ . on
17. SUBJECT TO FORM NUMBERS: (INSERT FORM NUMBERS AND EDITION DATES)
18 Deductible Deductible Deductible Percent of Coinsurance
' Windstorm and Hail Other Perils . Misc. (Explain) Applicable
$ $ $ %
m
19. OTHER INSURANCE (LIST NAMES OF COMPANIES AND AMOUNT IN EACH)
' . ' - - - - . 21. Home or General Fieldman Dated
20. REMARKS. Brief Description of Damage (If emergency handling reqmred, explain why) COPIES ’ Dept. Office Agent
SENT To
‘..__...—..__...._...—....-..........__._...........__..__—.....—|
| FOR ””57“”. > CATASTROPHE SERIAL N0. CAT. ZONE NO. |
: LOSSES GILT :
--__--_-___..___-..---___-..__-—__-__--__..__..____.I
I NAME OF ADJUSTER TO WHOM COPY THIS NOTICE HAS BEEN FORWARDED l
I
I___-_-______-______-__-____-____-_____-________.-
LEAVE SPACE BELOW FOR COMPANY USE ONLY
INSTRUCTIONS TO AGENTS:* Insert amount of insurance in appropriate column to the left. Description of coverage may be abbreviated below, i.e., Additional Living Expense - A.L.E.,
Improvements and Betterments - I. & 8., Builder's Risk ~ B.R.. Time Element Coverages - T.E.. Errors & Omissions - E.&0., Live Stock . L.S.. Machinery & Equipment - M.&E.. Furniture
& Fixtures - F.&F., Stock - Sk., Yard Fixtures - Y.F. Do not commit the Company to any claim or line of action unless specifically instructed to do so. UNDER NO CIRCUMSTANCES MAKE
ANY CHANGE OR ENTRY ON A POLICY AFTER A LOSS.
RECOMMENDED BY THE AMERICAN INSURANCE ASSOCIATION 8-65 .... FORM No. 5

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