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About Us
Program Features
Applications
Claims
Property
Liability
Contact Information
Loss Control
Payments
Contact Us
General Liability Claim Form
General Liability Claim Form
Jamie Glass
2015-02-10T00:20:29-05:00
Insured Information
Policy number
Named Insured as on Policy
Broker
Insured Contact Name
*
Insured Contact Phone
Email of Insured Contact
*
Description of Occurance
Date
*
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
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General Liability Claim Form
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