Tobacco Documents Online

KEMPER TELEPL US General Liability Reporting Form Fax No.: 708-320-4484 Company Name: Lumbermens Mutual Casualty Co. Policy No.: 5AA 038 170-00 A. INSURED INFORMATION/CONTACT Division/Subsidiary: Phi(ip Morris U.S.A. Location Code: C8300 Name & Title: Ellen Dimech. Claims Coordinator Address: 800 Westchester Ave.. Rye Brook NY 10573-1301 Business Phone: 914-335-1681 B. LOSS INFORMATION Loss Date: 7/11 95 Time ofLoss: am/pm Accident State: PA Date of Notification: 7/13/95 Was the accident on the Insured Premises? Yes No X If No, LOCATION OF ACCIDENT: ~ Address: Authority Contacted (i.e., police or fire dept): Description ofAccident: Alle eg cigarette "popped" and sustained 2nd degree burns to fin ers. Idjhat type of Liability is involved? General _ Product X 6i7tat type of Loss is involved? Injury X Property Both C. INJURED PERSON (If Applicable) Name: Jennifer L. Groff Address: P.O. Box 330. Nottingham, PA 19362 Home Phone: 610-932-8741 Business Phone: Age: 23 Sez: Nt F X Occupation: D. EMPLOYER OF INJURED PERSON (For contact during the day) Name: Address: Business Phone: Eet: E. INJURY DESCRIPTION (If Applicable) Describe Injury: 2nd degree bums to fingers Fatality? Yes _ No X If Yes, give date: Where was injured taken? Ilospital _ Doctor X Name: Richard Stratchko. M.D. Address: Wbat ivas the injured doing? Cigarette alle rr. edly popped after third puff. 1 07/17/95

A OWNER OF DAMAGED PROPERTY (If Applicable) Name: Address: Home Phone: Business Phone: G. DAMAGED PROPERTY DESCRIPTION (If Applicable) Was the damaged property a vehicle? Yes _ No i VEHICLES ONLY Year: Make: Model: Plate: State: VIN: OTHER PROPERTY ONLY i Describe datnaged property: Estimated antount of damage: $ Where can property be seen? When can it be seen? H. PRODUCT INFORMATION (If Product Liability) Product Name: Marlboro 100's Hard Pack Alleged Complaint: Alle ed cigarette "popped" Where Purchased? Who has possession of the Product/Foreign Object? Claimant has possession of product. Arrange pick-up from consumer and mail to: David Curle. Philip Morris USA, Onerations Center/Oualitv Assurance Dept.. 2001 Bells Rd.. Gate S. Door 100. Richmond, VA 23234. Your authority limit: $ L ATTORNEY (If Applicable) Nante: Address: Business Phone: J. WITNESS INFORMATION (If Applicable) Nance: Address: Home Phone: Business Phone: K GENERAL LOSS INFORMATION Name and Title of person reporting accident: Ellen Dimech, Claims Coordinator General Remarks: Adjuster should call above at 914-335-1G81 immediately. Arrangg pick-up of product. May be cigarette load placed following purchase. 0 m w ra m a ~ ~ O 2 07/17/95