Liability Claim

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Liability Claim

General Information

Policy Number

Date of Accident / Occurrence

Time of Accident / Occurrence

Date Claim Reported

05/02/2025

Insured / Policyholder Information

Please select:

First Name

Last Name

Primary Contact Information

First Name of Primary Contact

Last Name of Primary Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Ext.

Cell Phone

Email Address

Claimant Information

First Name

Last Name

Address

City

State

Zip

Phone

Alternate Contact Information

First Name of Alternate Contact

Last Name of Alternate Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Ext.

Cell Phone

Email Address

Information Regarding Accident / Occurrence

Address/Location of Accident / Occurrence

Type of Liability

Severity of Liability

Brief Description of Injury or Damage

Additional Information

First Name of Person Reporting Claim

Last Name of Person Reporting Claim

Title / Relationship to Insured

Enter your email address here if you would like to receive an electronic confirmation that this claim has been successfully submitted.

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Liability Claim

Locate an Agent

Liability Claim

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