# Always here to help
in this section
Submit a Claim: General Liability

Complete the form below and click the "Continue" button to review your information. You will need to click the "Submit Claim" button on the next page to complete your claim submission.

 

Agency Name:

Agent Phone:

Policy Number:

Date of Loss (required):
  

Time of Loss:
:

INSURED

Insured Name (required):

Insured Address:

Insured Residence Phone (required):

Insured Business Phone:

Insured Contact Person Name:

Insured Contact Person Residence Phone:

Insured Contact Person Business Phone:

LOSS

Location of Occurrence (required):

Police or Fire Dept. to which reported:

Description of Occurrence (required):

INJURED/PROPERTY DAMAGED

Injured/Property Owner Name & Address:
Injured/Property Owner Residence Phone:

Injured/Property Owner Business Phone:

Injury Description:

Fatality?:
Yes No

Where taken?:

Property Damage Description:

WITNESSES OR PASSENGERS

Name & Address Business Phone Residence Phone
1
2

Remarks:

Reported By: