Report an Incident

Please fill out the following form in order to submit a claim.

Basic Information

Date of Occurrence:*
Time of Occurrence:*
Policy Number:
Insured Name:*
Insured Address1:*
Insured Address2:
Insured City:*
Insured State:*
Insured Zipcode:*
Insured Residence Phone:
Insured Business Phone:*
Contact Name:*
Contact Address1:*
Contact Address2:
Contact City:*
Contact State:*
Contact Zipcode:*
Contact Residence Phone:
Contact Business Phone:*

Incident Information

Location of Occurrence:*

Description of Occurrence:*

Insured is:* Owner Tenant
Injured Name:*
Injured Address1:*
Injured Address2:
Injured City:*
Injured State:*
Injured Zipcode:*
Injured Phone:*
Injured Age:*
Injured Occupation:
Injured Employer Name:
Injured Employer Address1:
Injured Employer Address2:
Injured Employer City:
Injured Employer State:
Injured Employer Phone:
Discribe Injury:

Fatality: No Yes
Where was Injured Taken?:
What was Injured Doing?:

Witness 1

Witness 1 Name:
Witness 1 Address1:
Witness 1 Address2:
Witness 1 City:
Witness 1 State:
Witness 1 Zip:
Witness 1 Business Phone:
Witness 1 Residence Phone:

Witness 2

Witness 2 Name:
Witness 2 Address1:
Witness 2 Address2:
Witness 2 City:
Witness 2 State:
Witness 2 Zip:
Witness 2 Business Phone:
Witness 2 Residence Phone:

Witness 3

Witness 3 Name:
Witness 3 Address1:
Witness 3 Address2:
Witness 3 City:
Witness 3 State:
Witness 3 Zip:
Witness 3 Business Phone:
Witness 3 Residence Phone:

Remarks:


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Adult Residential Care Facilities are in good hands with PCALIC, not just for insurance, but also for vital educational materials we receive from them that enhances staff training and program evaluations. We thank you!

- MILLER & SON PCH, INC.