General Liability Notice of Occurrence/Claim

Policy Number
Policy Date From
Date Format: MM slash DD slash YYYY
TO
Policy Date
Date Format: MM slash DD slash YYYY
Producer Name
INSURED INFORMATION
Name
Address
Street Address City ZIP / Postal Code
State
Primary Phone
Alternate Phone
Email Address
CONTACT INFORMATION
If Different from Insured
Name
Address
Street Address City ZIP / Postal Code
State
Primary Phone
Alternate Phone
Email Address
OCCURRENCE/CLAIM INFORMATION
Date of Occurrence
Date Format: MM slash DD slash YYYY
Time of Occurrence

: HH

MM
Reported by
Location of Occurrence
Description of Occurrence
INJURED/PROPERTY DAMAGED
Name
Address
Street Address City ZIP / Postal Code
State
Age
Sex
Occupation
Employer's Name & Address
Phone
Alternate Phone
Describe Injury
- Fatality
Where Taken
What was Injured Doing?
Describe Property
Estimate Amount
Where can Property be Seen?
FIRST WITNESS
Name & Address
Phone Number
Alternate Phone Number
SECOND WITNESS
Name & Address
Phone Number
Alternate Phone Number
Remarks
APPLICABLE IN CALIFORNIA

PRIVACY NOTICE: Your privacy is important to us. To learn more about the categories of personal information we collect through this form, and how we use this information, please visit our privacy policy here.

For your protection, California law requires the following to appear on this form: Any person who knowingly presents 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.

APPLICABLE IN NEVADA

Pursuant to NRS §686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

APPLICABLE IN WASHINGTON

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

APPLICABLE IN ARIZONA

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

General Liability Notice of Occurrence/Claim

TO

INSURED INFORMATION

CONTACT INFORMATION

OCCURRENCE/CLAIM INFORMATION

INJURED/PROPERTY DAMAGED

FIRST WITNESS

SECOND WITNESS

APPLICABLE IN CALIFORNIA

APPLICABLE IN NEVADA

APPLICABLE IN WASHINGTON

APPLICABLE IN ARIZONA