Claims Loss Report - LIABILITY

Fill in the information below for General Liability Notice of Occurrence/Claim. * must be filled out

Date of Loss * +

Policy Number *

Insured Name *

Insured Email Address

Insured Phone Number *

Insured Contact Name *

Insured Address *

Loss Location *

How did the loss occur? Provide detailed description. *

If you are not the insured, what is your relation to the insured? *

Parties/Witness Involved

Name

Phone Number

Name

Phone Number

Name

Phone Number

Please attach any document related to this loss

FRAUD WARNING:

GENERAL: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime, subject to criminal prosecution and civil penalties .

CALIFORNIA: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NEW YORK & NEW JERSEY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, shall also be subject to criminal prosecution and [NY: substantial] civil penalities.