Report a General Liability Claim

Please complete the form below to report a general liability claim. A claims representative will contact you within 1-2 business days.

First Name *

Last Name *

Company Name *

Phone Number *

Email Address *

Policy Number *

Named Insured *

Date of Loss *

Time of Loss

Location of Loss (Address) *

City *

State *

Zip Code *

Description of Loss *

Were there any injuries?

Describe Injuries

Was there any property damage?

Describe Property Damage

Claimant Name

Claimant Phone

Claimant Address

Witness Name

Witness Phone

Additional Information