| Notice of: |
Occurrence
Claim
|
| *Date
and Time of loss: |
|
| *Insured
Company Name: |
|
| *Contact Name: |
|
| *Contact Phone #: |
|
|
LOSS
|
| Location of Occurrence: |
|
| Authority Contacted: |
|
| Description of
Occurrence: |
|
| TYPE OF LIABILITY |
| Premises: |
Yes
No
|
| Insured is: |
Owner
Tenant
Other
|
Owner Name and Address:
(if other than insured) |
|
| Owner's Phone: |
|
| Type of Premises: |
|
|
|
Products: |
Yes
No
|
| Insured is: |
Manufacturer
Vendor
Other
|
Manufacturer Name and Address:
(if other than insured) |
|
| Manufacturer's Phone: |
|
| Type of Product: |
|
| Where can Product be seen? |
|
|
|
Other Liability: |
Yes
No
|
| Explain: |
|
|
INJURED/PROPERTY DAMAGED
|
Name and Address:
(Injured/Owner) |
|
| Phone: |
|
| Age: |
|
| Gender: |
Female
Male
|
| Occupation: |
|
| Employer's Name and Address: |
|
| Employer's Phone: |
|
| Describe Injury: |
|
| Where Taken: |
|
|
What was injured doing? |
|
|
Fatality? |
Yes
No
|
Describe Property:
|
|
|
Estimate Amount: |
|
| Hire Date: |
|
| Where can property be seen? |
|
|
WITNESSES
|
| Name and Address: |
|
| Business Phone:
|
|
| Residence Phone: |
|
|
|
| Name and Address: |
|
| Business Phone:
|
|
| Residence Phone: |
|
|
|
| Name and Address: |
|
| Business Phone:
|
|
| Residence Phone: |
|