Liability Claim Form

LIABILITY CLAIM
*(ITEMS MARKED WITH '' ARE REQUIRED)**
GENERAL INFORMATION
* Preparer's Name:
* Date Prepared:
* Preparer's Email Address:
INSURED INFORMATION
* Claim Date:
Previously Reported?	Yes No
* Date of Loss:
Time of Loss:	A.M. P.M.
Location Code:
* Location of Loss:
* Description of Loss:
POLICY INFORMATION
* Policy Number:	General Liability Umbrella Excess
PREMISE LIABILITY
Insured Is:	Owner Tenant Other
Owner Name (if not insured):
Mailing Address:
City:
State:
ZIP Code:
Owner Phone:
Type of Premise:
PRODUCT LIABILITY
Insured is:	Manufacturer Vendor Other
Manufacturer's Name (if not insured):
Mailing Address:
City:
State:
ZIP Code:
Manufacturer's Phone:
Type of Product:
Where can product be seen?
INJURED
Injured's Name:
Mailing Address:
City:
State:
ZIP Code:
Injured's Phone:
Age:
Sex:	Male Female
Occupation:
Description of Injuries:
Fatality?	Yes No
Where taken?
What was injured doing?
Employer Name:
Mailing Address:
City:
State
ZIP Code
PROPERTY DAMAGE
Owner's Name:
Mailing Address:
City:
State:
ZIP Code:
Owner Phone:
Describe Property:
Estimate Amount:	$
Where can property be seen?
When can property be seen?
INSURED INFORMATION
Name:
Mailing Address:
City:
State:
ZIP Code:
Residence Phone Number:
Business Phone Number:
CONTACT INFORMATION
* Name:
Mailing Address:
City:
State:
ZIP Code:
Phone Number:
Where to Contact:
When to Contact:
REMARKS