General Liability Notice of Occurrence / Claim

Please complete the form below. Once we have received it, a team member will be in touch with you.


Important Information

Name

Company Name

Date (mm/dd/yyyy)

Agency

Phone Number

Fax Number

Email Address

Code

Sub Code

Agency Customer ID


Notice of Occurrence/Claim

Date of Claim (mm/dd/yyyy)

Time of Occurrence (indicate AM or PM)

Previously Reported:
Yes No

Effective Date (mm/dd/yyyy)

Expiration Date (mm/dd/yyyy)

Policy Type:
Occurrence Claims Made

Retroactive Date (mm/dd/yyyy)

Company

NAIC Code

Policy Number

Site & Location Code

Reference Number


Insured Information

Name of Insured

Street Address

City

State

Zip Code

Phone Number

Email Address

Social Security Number or FEIN


Occurrence Information

Location of Occurrence (include City and State)

Description of Occurrence

Authority Contacted:


Policy Information

Coverage Part or Forms (include form numbers and edition dates)

General Aggregate:

Prod/Comp OP AGG:

Pers & Adv Inj:

Each Occurrence:

Fire Damage:

Medical Expense:

Carrier:

Deductible:

Umbrella/Excess:

Limits:


Type of Liability

Premises Insured Is:

If Other, Specify:

Owner's Name and Address

Product(s) Insured Is:

Manufacturer's Name and Address (if not insured)

Other Liability Including Completed Operations (explain)

Type of Premesis:

Owner's Phone

Type of Product:

Manufacturer's Phone


Injured/Damaged Property Information

Name and Address of Injured/Owner

Age

Gender

Employer's Name and Address

Describe Injury

Where Taken

What was Injured doing?

Describe Property (type, model, etc.)

When Can Property Be Seen?

Estimate Amount


Witness Information

Name and Address of Witness

Remarks

Witness Phone Number

Reported By:

Reported To: