General Liability Loss Notice

General Liability Loss Notice

1
Named Insured
2
Contact
3
Claimant
4
Loss
5
Final Remarks
Step 1: Named Insured
I am the
Agency
Named Insured
Policy Number
Mailing Address
City
State
ZIP Code
Primary Phone Number
Secondary Phone Number
Email

Step 2: Contact
Name of Contact (First, Middle, Last)
Primary Phone Number
Secondary Phone Number
Contact's Mailing Address
City
State
ZIP Code
Email
When to Contact
Step 3: Claimant
Name (Injured/Owner)
Contact's Mailing Address
City
State
ZIP Code
Primary Phone Number
Step 4: Loss
Address of Liability Occurrence
City
State
ZIP Code
Date of Occurrence
Description of Liability Occurrence
Describe Injury/Property Damage
Witness Information
Step 5: Final Remarks
Remarks/Other Insurance (list companies, policy numbers and coverages)
Reported By
Reported To
Disclaimer
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

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