General Liability Loss Notice

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.

All fields with an (*) are required

Policy Holder Information

Name of Insured (As it appears on the policy) *

Address

Street

City

State

Zip Code

Home Phone

Work Phone

Email Address *

Insurance Company Name *

Insurance Policy Number *

Time and Description of Loss

Time and Date of Loss *(7:42 pm, December 5, 2007)

Location of Property *

Description of Loss *

Property Status

Is the Property habitable?

Yes

If No, where are you staying? (Address & Phone)

Authority Notification

Where the Police or Fire Department Called?

Yes

If Yes, which authority

Report Information

Reported By

Title (If Any)

Date

Additional Comments

Comments *

Please type the two words in the image in the text box below. * Unfortunately, this is necessary to prevent automated form submissions. Thank you for your cooperation.

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