GENERAL LIABILITY NOTICE/CLAIM
Date: Date of Claim:
Date of Occurrence:Policy Number:
Time of Occurrence:AMPMPreviously Reported: YesNo
Agency: Agency Phone:
Insured InfoContact Info
Name:Name:
Address:Residence Phone #:
City:Business Phone #:
State: Zip:Cell Phone #:
Residence Phone #:Email Address:
Business Phone #:Where to Contact:
Cell Phone #:When to Contact:
Email Address:
Occurrence
Authority Contacted:
Location of Occurrence (include City & State):
Description of Occurrence:
Injured/Property Damaged
Name (injured/owner):
Address: City:
State:Zip:
Age:Sex:
Occupation:Employers Phone #:
Employers Name   & Address:
Describe Injury:
Where Taken?:
What was Injured Doing?:
Describe Property:
Estimate Amount:
Where can Property be seen:
When can Property be seen:
Witness
Name:
Address:City:
State:Zip:
Residence Phone:Business Phone #:
Remarks:
Reported By:
"Any person who knowingly and with intent to defraud any insurance company or other person files and application for insurance or statement of claim containing any materially false informaiton, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
The person completing this Loss Notice hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.