Liability Claim Form

The items marked with an * are required. This form will be sent electronically to our claims department.

Policyholder Information:

  

*Insured's Name:

Insured's DBA:

Address:

City:

State:

Zip/Postal:

*Daytime Phone:

*Policy Number:

 

Contact Information:

  

*Contact Name:

Relation to Policyholder:

Daytime Phone:

*E-mail:

 

Loss Report:

  

Was Loss Previously Reported?:

 Yes  No

*Date of Loss:

   Check if Unknown

Time of Loss:

Location of Loss:

Address:

City:

State:

Zip/Postal:

Authorities Contacted?:

Yes  No

If yes: Agency Contacted:

Report Number:

Type of Loss:

Damage to Property
  Bodily Injury
  Liquor Liability
  Professional Liability
  Other

 

Individual Involved in Loss:

  

*Claimant Name:

Address:

City:

State:

Zip/Postal:

Telephone:

Injuries Sustained:

Loss Description:

Property Damaged:

Property Owner Name:

Property Owner Address:

City:

State:


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