General Liability Claim

Please complete as much information as possible. At a minimum, please provide your contact information so that we can assist you with processing your claim.

Accident Date
Accident Time	am pm
Policy Number

Insured Information
Insured Name
Address
City, State Zip	,
Residence Phone
Business Phone

Contact Information
Contact Name
Contact Address
City, State Zip	,
Where to Contact
When to Contact

Occurrence
Location of Occurrence
City, State	,
Authority Contacted
Report #
Description of Occurrence
Type of Liability
Premises: Insured Is	Owner Tenant Other
If Not Insured
Name
Address
City, State	,

Injured/Property Damaged
Injured/Owner's Name
Injured/Owner's Address
City, State	,
Residence Phone
Business Phone
Injured/Owner's Age	Years Sex Male Female
Occupation
Description of Injury	Fatality Yes No
Where Taken (hospital or...)
What was injured doing?

Witnesses
Name
Address
City, State Zip	,
Residence Phone
Business Phone

Submitted by
Name
Agency
Address
City, State	,
LOC Code
Date of Claim
Phone
Fax
Email