General Liability

General Liability Claim Form

*Required

Agent Information Section
Agent Name:
Policy Number:

Insured Information Section
Name:*  
Address:

Please provide at least one of the following
Residence Phone:
Cell Phone:
Business Phone:
Email Address:  

Contact information (if different from named insured)
Name:
Address:
Residence Phone:
Cell Phone:
Business Phone:
Email Address:  

Loss Information Section
Date of Occurrence:*   mm/dd/yyyy
Time of Occurrence:*  
Location of Occurrence:*  
Type of Occurrence:
Description of Occurrence:*  
Police or fire department to which the loss reported, if any.
Additional Comments if Any:

Type of Liability Information Section
Premises: Our Insured Is
Owners name and address (if not our insured):
Type of Premises:
Owners Phone number or contact number:

Injured/Property Damaged Section
Name of Injured Party/Owner of Damaged Property:
Address of Injured Party/Owner of Damaged Property:
Residence Phone:
Cell Phone:
Business Phone:
Email Address:  
Describe injury or damage to property:

Witness Information Section
Name:
Address:
Residence Phone:
Cell Phone:
Business Phone:
Email Address:  

Reporting Information Section
Your Name:*  
If not reported by our insured, complete the information below
Your Phone Number:
Your relationship to insured:
Additional Comments if Any:
   
(New Jersey) Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

(Maryland) Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

(Pennsylvania) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.



Report a Claim

You may also contact our Claims Department
by phone at 800.498.0954