Liability Claim -

Liability Claim :: First Report Form

For claims made by third parties alleging Bodily Injury or Property Damage...

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

Named Insured *

Address

Country

City

State

Zip code

Phone *

Email *

Claimant *

Name of person who makes a claim against you

Claimant Address

Country

City

State

Zip code

Claimant Phone *

Contact

Person to contact for claimant

Incident / Injury Information

Date of Incident *

Time of Incident *

Location of Incident

Country

City

State

Zip code

Name of authority and report number

Description of Incident / Injury

Damage

Describe property damage (type, model, etc.)

Estimate Amount of Loss

(in dollars)

Property Location

Where property can be seen by company adjuster

Form Verification (this proves you're not a robot!)

Please enter any two digits with no spaces (Example: 12) *