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

Home Phone

WorkPhone

Insurance Policy #

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
No

If No, where are you staying? (Address and Telephone)

Authority Notification

Were the Police or Fire Department Called?
Yes
No

If yes, what authority?

Report Information

Reported by

Title (if any)

Date

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

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