GENERAL LIABILITY NOTICE OF OCCURRENCE / CLAIM

Imp.. Information

DATE(MM/DD/YYYY): AGENCY: PHONE(A/C, No, Ext): FAX(A/C, No): E-MAIL ADDRESS: CODE: SUB CODE: AGENCY CUSTOMER ID:

NOTICE OF OCCURRENCE NOTICE OF CLAIM

DATE OF OCCURRENCE AND TIME: AM PM
DATE OF CLAIM:
PREVIOUSLY REPORTED: Yes No
EFFECTIVE DATE: EXPIRATION DATE:
POLICY TYPE: OCCURRENCE CLAIMS MADE
RETROACTIVE DATE: COMPANY: NAIC CODE: POLICY NUMBER: MISCELLANEOUS INFO (Site & location code): REFERENCE NUMBER:

INSURED

NAME AND ADDRESS: SOC SEC # OR FEIN:
RESIDENCE PHONE (A/C, No): BUSINESS PHONE (A/C, No, Ext):
CELL PHONE (A/C, No): E-MAIL ADDRESS:

CONTACT

CONTACT INSURED:
NAME AND ADDRESS: RESIDENCE PHONE (A/C, No):
BUSINESS PHONE (A/C, No, Ext): CELL PHONE (A/C, No):
E-MAIL ADDRESS: WHERE TO CONTACT:

OCCURRENCE

LOCATION OF OCCURRENCE (Include city & state):
DESCRIPTION OF OCCURRENCE (Use separate sheet,if necessary):
AUTHORITY CONTACTED:

POLICY INFORMATION

COVERAGE PART OR FORMS (Insert form #s and edition dates):
GENERAL AGGREGATE:
PROD/COMP OP AGG:
PERS & ADV INJ:
EACH OCCURRENCE:
FIRE DAMAGE:
MEDICAL EXPENSE:
DEDUCTIBLE:	PD BI
UMBRELLA/EXCESS:	UMBRELLA EXCESS
CARRIER:
LIMITS:	AGGR PERCLAIM/OCC SIR/DED

TYPE OF LIABILITY

PREMISES INSURED IS:	OWNER TENANT
OTHER:
OWNER'S NAME & ADDRESS(If not insured):
PRODUCTS INSURED IS:	MANUFACTURER  VENDOR
MANUFACTURER'S NAME & ADDRESS (If not insured):
WHERE CAN PRODUCT BE SEEN?
OTHER LIABILITY INCLUDING COMPLETED OPERATIONS (Explain):
TYPE OF PREMISES:	California -- CA Colorado -- CO Connecticut -- CN
OWNERS PHONE(A/C, No, Ext):
TYPE OF PRODUCT:	California -- CA Colorado -- CO Connecticut -- CN
MANUFACT PHONE(A/C, No, Ext):

INJURED/PROPERTY DAMAGED

NAME & ADDRESS(Injured/Owner):
AGE:
SEX:	MALE FEMALE
OCCUPATION:
EMPLOYER'S NAME & ADDRESS:
DESCRIBE INJURY:
WHERE TAKEN:
WHAT WAS INJURED DOING?
DESCRIBE PROPERTY (Type, model, etc):
ESTIMATE AMOUNT:
WHEN CAN PROPERTY BE SEEN?:

WITNESSES

NAME & ADDRESS:
BUSINESS PHONE (A/C, No, Ext):
RESIDENCE PHONE (A/C, No):
REMARKS:
REPORTED BY:
REPORTED TO:
SIGNATURE OF INSURED:
SIGNATURE OF PRODUCER: