General/Product Liability Claim Report

View Form Instructions

Date(Required)

Insured Name(Required)

First Last

Address/Loss Location(Required)

Street Address Address Line 2 City State

County

Zip Code

Description of Alleged Incident(Required)

Information on Injured Party / Property Owner

Name

First Last

Phone

Address

Street Address Address Line 2 City State

County

Zip Code

Witnesses

Name

First Last

Phone

Address

Street Address Address Line 2 City State

County

Zip Code

Lawsuit Filed?

County & State Where Filed

County State

Date of Service

Reported By(Required)

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Instructions

If there is any reason that you need to be contacted immediately, please let us know.

Provide all documents you have regarding this incident.

Copy of lawsuit, if filed

Documents provided by claimant including medical bills.

Internal documents including any investigation of the incident, repair and maintenance records, etc.

Names and address of any witnesses to the incident or employees who may be able to provide details on the product
or location involved in the incident.

If a product is involved & you have the product, save this for inspection by the claims adjuster or an expert named by
the insurance company.

The claim adjuster will deal directly with the claimant or his/her attorney; you should not deal with them yourself.

Expect to be contacted by the claims adjuster within 48 hours.

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