Web Reported Claim

General Liability Claim

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Begin The Claim

What is your relationship to the claim?

Policyholder Claimant Attorney Agent Other

Your First Name*

Your Last Name*

Your Address*

Your City*

Your State*

Your Zip*

Your Home Phone

Your Work Phone

Your Extension

Your Cell Phone

Your Email (A copy of this Web Reported Claim will be sent to the below e-mail address.)

Date of Loss*

Time of Loss

Claim Type*

Policyholder

Check if same as person reporting the claim

Yes No

Company Name*

First Name*

Last Name*

Address

City

State

Zip

Home Phone

Work Phone

Extension

Cell Phone

Preferred Contact

Policy #

Claim Details

Check if same as Policyholder

Yes No

Loss Location*

Building/Location#

City*

County*

State*

Zip*

Briefly describe what happened in the incident and specify the damage/injury

Were local authorities notified or on the scene?

Yes No

Agency Name/Precinct

Cause of Loss

Is the property habitable?

Yes No

Is there structural damage?

Yes No

Catastrophe Codes

Estimated amount of entire loss

Summary

Your claim is now ready to submit.

Is there anything else that you would like to note?

Attachments

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