General Liability Notice of Insurance / Claim
Please use the form below to notify our agency about a claim towards your policy. You will contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.
Agent Information:
Agency:
Agent Name:
Phone:
Fax:
Agent E-Mail Address:
Policy Holder Information
Name Insured
(As it appears on the policy):
Address:
Phone #: Work     Home
Email:
Insurance Company Name:
Policy #:
Time and Description of Loss
Time & Date of Loss:
Time a.m.
p.m.		     Date
Location of Property:
Description of Loss:
Authority Notification
Was the Police or Fire Dept. notified? Yes     No
If Yes, which Authority?
Report Information
Reported by:
Title (if any):
Date:
Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice. Including description of injury, property, & witnesses.
    
Applicant Signature/Print Name
Agent/Producer Signature/Print Name