Liability Claim First Report Form

Claim Details
Name of Claimant*
Address of Claimant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Liability Claim Information
Person to Contact for Claim*
Date of incident / injury: *

MonthDayYear
Date
Location*
Authority Contacted:*
Please give a detailed description of the incident / injury:*
Estimated amount of loss:*
Where can property be seen by company adjuster?*
The original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.

Claim Details