General Liability Claim Form

Insured Information

Policy number

Named Insured as on Policy

Broker

Insured Contact Name*

Insured Contact Phone

Email of Insured Contact*

Description of Occurance

Date*

Loss Location

City, State, Zip

Loss Type

BI
PD

Accident Details / Description

Claimant Information

Name

Claimant Address

Street Address Address Line 2 City State ZIP Code

Contact Phone

Attorney Information (if applicable):

Injuries / Treatmen t /Property Damage:

Reported by Name / Contact Number:

Reported by Name

Reported by Phone

Additonal Comments:

Please attach the following:
1. Acord Forms
2. Summons
3. Letter of Representation
4. Medical Records (if available)
5. Estimates for property damage (if applicable)
6. Photos
7. Statements/Incident reports

File

Max. file size: 256 MB.

General Liability Claim Form

Insured Information

Description of Occurance

Claimant Information

Reported by Name / Contact Number:

Claim Forms & Applications