General Liability Claim Form

Use the form below to submit a general liability claim to our claims department.Required fields are in red.

Entity Name
Entity Contact Name
Entity Contact Phone
Entity Contact Email	(Used to send copy of submitted form)
Date of Incident
Person Making Claim
Address of Person Making Claim
Phone # of Person Making Claim
Describe Injury or Property Damage
Location of Incident
Date Reported to Entity
Person Reported To
Description of Incident
Witnesses (include contact information)
Why do you feel your entity is responsible for this incident?