Insurance Services Department

Insurance Services Department
Phone: (716) 847-8396
Fax: (716) 847-5538

Claim Forms that can be completed and sent directly to the Insurance Services Department via the internet:

Property Loss Notice - This includes losses to buildings and contents, theft losses and losses due to breakdown of boilers or machinery.

Incident Report - This form is to be used to report injuries involving non-employees (other than auto accidents).

Automobile Loss Notice - This form is used to report auto accidents (with or without injuries involved) involving Diocesan/Parish owned or priest personally owned autos that are part of the priests' auto policy.

Claim Forms that can be downloaded and sent via fax.

Please Note: The file(s) referenced below are in Adobe PDF format. To view or print this PDF file downloaded from this web site, you must have Adobe Acrobat Reader Version 4.0 or later.

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(Approximate download time for the 6.3 MB file is 45 minutes with 56K modem. The following system requirements are needed to run Adobe Acrobat Reader Version 5.0:

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	C-2 Employers Report of Accident (Workers' Compensation) Once downloaded, fill in the appropriate fields, and print the form. Fax to the Insurance Services Dept. @ 847-5538.
	DB-450 Notice of Proof of Claim for Disability Benefits (Note: Due to the large size of this file, it may take several minutes to download depending on your connection speed). Once downloaded, print the form and complete the appropriate information. Obtain claimant's signature on the form and fax to the Insurance Services Dept. @ 847-5538.
	K-12 Student Accident Claim Form Once downloaded, fill in the appropriate fields in the "Employers" section. Print the form, sign it, then send to the parent/guardian of the injured student. fax a copy to the Insurance Services Dept. @ 847-5538

Insurance Services Department Phone: (716) 847-8396 Fax: (716) 847-5538

Insurance Services Department
Phone: (716) 847-8396
Fax: (716) 847-5538