Claims

General Liability Claim Alert Form

If you would like us to report the claim to your insurance company on your behalf please complete the below form.

Date of Loss*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Policy Number*
Your Full Name*
Company Name*
Your Address*
Street Address City State / Province / Region
Your Phone*
Email*
Names of All Parties Involved
Who was Notified?*
- Police
- Agency
- Others
Description of Incident and Action Taken*
(Attach additional information, official reports & photos [see next page])
Injury Information
Type and extent of injury known*
Name of injured Party*
Phone*
Address*
Street Address City State / Province / Region
Damage to Others’ Property
Description of Property & Damage (Age/Make/Model/Cost of Repairs)*
(Attach additional Information if available)
Name of Owner*
Phone*
Address*
Street Address City State / Province / Region
Witnesses
Name*
Phone*
Address*
Street Address City State / Province / Region
Name*
Phone*
Address
Street Address City State / Province / Region
Reported by*
Date*
MM slash DD slash YYYY
SUGGESTIONS FOR REPORTING GENERAL LIABILITY CLAIM

Were photographs taken? Please include originals (photocopies are seldom adequate).

Was a police report / incident report created? Please include copy(ies).

The more detail you can supply, the better.

WE WILL FORWARD THIS COMPLETED FORM TO YOUR INSURANCE COMPANY BUT YOU ARE RESPONSIBLE FOR READING YOUR POLICY FOR CLAIM REPORTING PROCEDURES AND COVERAGES
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Accepted file types: jpg, png, gif, pdf, docx, doc, ppt, tiff, jpeg, Max. file size: 50 MB, Max. files: 5.