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It collects details such as type of claim, dates of loss, insured information, policy period, incident description, related prior claims, internal investigation status, and whether the matter involves demand letters or litigation. It also gathers information from brokers, counsel, defense firms, and claimant parties, and includes state-specific fraud warning language and an updated form reference.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/arch-claim-or-incident-reporting-form/280817/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/arch-claim-or-incident-reporting-form/280817.png","ImageObject",442,249,{"name":88,"@type":89},"Cipher","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does the insured need to complete on the form?","Question",{"text":108,"@type":109},"The form requires the insured (or representative) to provide claimant/incident description, incident address, insured name, policy number, applicable policy period, and dates such as today’s date and the date of loss. It also collects contact information and preferred method of contact.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form address coverage and investigation status?",{"text":113,"@type":109},"It asks which insuring agreement(s) the filer is seeking coverage under and whether an internal investigation has been undertaken. If an investigation occurred, relevant information and findings must be provided.",{"name":115,"@type":106,"acceptedAnswer":116},"What attachments are required when submitting the claim?",{"text":117,"@type":109},"The claimant or counsel section requests attaching claim-related documents, investigative materials, claim communications, summons, complaints, pleadings, and any referenced enclosures or attachments.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},280817,1789558827,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":73},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Arch Claim or Incident Reporting Form  \nUpon completion, please email or fax this form to [Claims@ArchInsurance.com](Claims@ArchInsurance.com) or 866.266.3630  \nType of Claim/Line of Business (if known):  \n􀂆 Commercial General Liability 􀂆 Employment Practices Liability 􀂆 Property  \n􀂆 Crime 􀂆 Fiduciary 􀂆 Professional Liability  \n􀂆 Cyber 􀂆 Healthcare 􀂆 Third Party Administered Claims  \n􀂆 Directors and Officers 􀂆 Kidnap, Ransom and Extortion  \nToday’s Date: (mm/dd/yyyy)   Date of Loss: (mm/dd/yyyy)    \nTO BE COMPLETED BY THE INSURED/INSURED’S REPRESENTATIVE:  \nClaim Form Completed By:   Relationship to Insured (if applicable):   Contact Information:   (phone)   (email) Description of Claim/Incident:  \nAddress of Claim/Incident (including Zip Code):   Insured’s Name:   Policy Number:   Applicable Policy Period:   Mailing Address:   Phone Number:   (w)   (m) Email:   Insured’s Contact Person:   Preferred Method of Contact:  email  phone Phone Number:   (w)   (m) Email:   Is this related to a previously reported claim?  YES  NO  \nIf YES, provide the information on the previously reported claim:  \n_______________________________________________________________________________________________  \nPlease identify under which Insuring Agreement(s) you are seeking coverage:  \nHas an internal investigation been undertaken?  \nYES  \n NO  \nIf YES, please provide all relevant information/findings:  \n_______________________________________________________________________________________________  \nIs this a Demand Letter?  YES  NO  \nIf so, what date did you receive the Demand Letter? (mm/dd/yyyy)    \nIs the claim in litigation?  YES  NO If so, what date was the Summons/Complaint received?    \n(mm/dd/yyyy)  \nPLEASE PROVIDE IF APPLICABLE:  \nName of Insured’s Broker:   Preferred Method of Contact:  email  phone Phone Number:   (w)   (m) Email:   Defense Counsel Firm Name and all Partners and Associates Assigned:  \nLead Partner Contact Information:  \nPhone Number:   (w)   (m) Email:   Partner/Associate/Paralegal Hourly Rates:   Was Other Insurance put on notice?  YES  NO  \nIf YES, please attach a copy of the Other Insurance Policy and coverage position, and complete the following:  \na. Date Other Insurance was put on notice: (mm/dd/yyyy)    \nb. Other Insurance Carrier Name:    \nc. Other Insurance Policy Type:    \nd. Policy Number:    \ne. Policy Period:    \nf. Policy Limit and Deductible/SIR:    \ng. Other Insurance Claims Handler’s Contact Information: Phone Number:   (w)   (m) Email:    \nTO BE COMPLETED BY CLAIMANT OR THEIR COUNSEL:  \nClaimant’s Name:   Address:  Phone:   SS\\#:   DOB:   Occupation:   Claimant’s Attorney:   Address:   Phone Number:   (w)   (m) Email:   Description of Claim/Incident:  \nAddress of Claim/Incident (including Zip Code):   Current Status of Claim/Incident:    \nPlease attach any and all claim related documents, investigative materials, claim communications, summons, complaints, any and all pleadings, and all referenced enclosures and/or attachments.  \nUpdated: 1/2019 MCGL-B00355  \nFraud Warnings by State  \nConnecticut, Georgia, Hawaii, Illinois, Iowa, Kansas, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, South Carolina, South Dakota, Vermont, Wisconsin, Wyoming  \nAny person who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison  \nAlabama  \nAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.  \nAlaska  \nA person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.  \nArizona  \nFor your protection Arizona law require","cbCaisxDX537CQtP","https://ap.wps.com/l/cbCaisxDX537CQtP","pdf",290197,"English","# Type of Claim and Key Dates\n## Today’s Date and Date of Loss\n# Insured Information and Incident Details\n## Claim Form Completed By and Contact Information\n## Description and Address of Claim/Incident\n## Policy Number and Policy Period\n# Coverage Requests and Investigation\n## Insuring Agreement(s) Sought\n## Internal Investigation Undertaken\n## Demand Letter and Litigation Status\n# Applicable Supplemental Information\n## Broker Information and Defense Counsel Details\n## Other Insurance Notice (if applicable)\n# Claimant or Counsel Section\n## Claimant Details and Current Claim Status\n## Required Attachments\n# Fraud Warnings by State","[{\"question\":\"What information does the insured need to complete on the form?\",\"answer\":\"The form requires the insured (or representative) to provide claimant/incident description, incident address, insured name, policy number, applicable policy period, and dates such as today’s date and the date of loss. It also collects contact information and preferred method of contact.\"},{\"question\":\"How does the form address coverage and investigation status?\",\"answer\":\"It asks which insuring agreement(s) the filer is seeking coverage under and whether an internal investigation has been undertaken. If an investigation occurred, relevant information and findings must be provided.\"},{\"question\":\"What attachments are required when submitting the claim?\",\"answer\":\"The claimant or counsel section requests attaching claim-related documents, investigative materials, claim communications, summons, complaints, pleadings, and any referenced enclosures or attachments.\"}]","Arch Claim or Incident Reporting Form | PDF"]