Liability Claim

Liability Claim :: First Report Form

In addition to filling out the form below, the original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.

Information About Our Insured
Name of person who makes a claim against you
Person to contact for claimant
Incident / Injury Information
Describe property damage (type, model, etc.)
(in dollars)
Where property can be seen by company adjuster
Form Verification (this proves you're not a robot!)