Liability Claim First Report Form
Insured Name *
Your answer
Policy Number *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Country *
Your answer
Contact Phone Number *
Your answer
Contact Email *
Your answer
Claimant Primary Contact Information
Name of Claimant *
Your answer
Address of Claimant *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Email *
Your answer
Liability Claim Information
Person to Contact for Claim: *
Your answer
Date of incident / injury: *
MM
/
DD
/
YYYY
Location *
Your answer
Authority Contacted: *
Your answer
Please give a detailed description of the incident / injury: *
Your answer
Please describe any property damage (Type, Model, etc.): *
Your answer
Estimated amount of loss: *
Your answer
Where can property be seen by company adjuster? *
Your answer
The original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.
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