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*
Date Format: MM slash DD slash YYYY
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