Liability Claims

Insured's Company Name:
        Contact Person at company:
        Best Phone # to reach contact:
Insurance Company:
Policy #:
Date of occurrence: Time of occurrence:


When did you first hear about incidence:
What happened:
Location:
(Physical address, name of business, etc.)

Injured Party's Info:

 
Name:
DOB: SSN:


Address:
Phone:
(The best way to reach him/her, please not if home, work, cell, etc.)
Part of body affected:
Did injured person leave by ambulance:
Where was person treated:
        Released or Admitted:
Treating Physician:
Will treatment be ongoing:

Witnesses:

 
Name: Phone:




   
** Please, be as specific as possible, the more details we have, the easier the claim process will be. However, if you do not know, or if the person will not give you that information, just leave it blank.