Claim Form

General Liability

General Liability
Information Item in red are required.
Your Company Information
Company Name
Address (Line 1)  
Address (Line 2)  
City  
State  
Your Contact Information
Name  
Telephone  
E-Mail Address  
Name of Person Reporting Claim
-Phone # (if different from above) 		 
Incident Information
Date of Incident    
Location of Incident  
Description of Incident  
Other Party's Information
OTHER PARTY (Name)  
O/P Address & Telephone# (daytime)  
Injuries/Damages  
Treated for Injuries?
 
By Whom?  
Witnesses  
Comments  
**Notes: Take photos of the area if possible

Have witnesses complete incident form.
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