Liability Claim

Policy Number

Date of Accident / Occurrence

Time of Accident / Occurrence

Date Claim Reported

04/19/2024

Please select:

Individual Business

First Name

Last Name

First Name of Primary Contact

Last Name of Primary Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Cell Phone

Email Address

First Name

Last Name

Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

First Name of Alternate Contact

Last Name of Alternate Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Cell Phone

Email Address

Address/Location of Accident / Occurrence

Type of Liability

Please make a selection Bodily Injury Property Damage Oil Tank Leak / Pollution Dog / Animal Bite Other

Severity of Liability

Please make a selection Minor Moderate Severe

Brief Description of Injury or Damage

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.