GENERAL LIABILITY CLAIMS REPORTING FORM
Policy No:

Policy Period:

Effective Date: Expiration Date:
Insured Name: Contact:
Insured Address:
Insured Phone Number:
Work:		 Home:
OCCURRENCE
Location of Occurrence: Authority Contacted:
Description of Occurrence:
TYPE OF LIABILITY
Premises: Insured is
Owner Tenant Other		 Type of Premises:
Owners Name and Address:

Phone No:
INJURED/PROPERTY DAMAGE
Name and Address of Owner:

Phone No:
Age:   Sex:
Occupation:		 Employers Name and Address:
Describe Injury:
 Where Taken:
Description of Damaged Property:
 Amount of Loss?
WITNESS
Name: Name:
Address: Address:
Phone Number: Phone Number:
Remarks:
Reported By:
 Contact Person:


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