FIRST NOTICE OF LOSS
General Liability
GB Account #: 010912
VDN: 2225720
Date of Incident
*
-
Month
-
Day
Year
Date
Authority Name
*
Reporting Party Name
*
First Name
Last Name
Reporting Party Email
*
example@example.com
Reporting party phone #
*
-
Area Code
Phone Number
Has Suit Been Filed?
*
No
Yes
Was there a death or severe injury?
*
Yes
No
Other
Details
Injured Party
*
First Name
Last Name
DESCRIBE WHAT HAPPENED
*
Please be as detailed as possible
Describe What Happened:
*
Location of Incident Street Address
Street Address, Specific Location (i.e. sidewalk, in unit, etc.)
City/Town/Village
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Were Security Cameras In Use?
*
No
Yes
Yes, no capture of event
Other
Was video footage saved and backed up? (If No, please take appropriate steps)
*
No
Yes
Other
Do you have a hired security service/firm at this location?
*
No
Yes
Other
Security Firm Name
INJURIES
Injuries?
*
Yes
No
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Additional party injuries?
Yes
No
Injured in VEHICLE #
Please Select
Driver Vehicle 1
Driver Vehicle 2
Driver Vehicle 3
Passenger Vehicle 1
Passenger Vehicle 2
Passenger Vehicle 3
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Additional party injuries?
Yes
No
Injured in VEHICLE #
Please Select
Driver Vehicle 1
Driver Vehicle 2
Driver Vehicle 3
Passenger Vehicle 1
Passenger Vehicle 2
Passenger Vehicle 3
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Attorney Rep?
*
Yes
No
Firm Name
Claimant Attorney Firm
Attorney Name
First Name
Last Name
Attorney Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney phone #
-
Area Code
Phone Number
Suit Filing Date
-
Month
-
Day
Year
Date
Please add any other significant information
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Georgia Fraud Advisement
GEORGIA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: Any natural person who knowingly and willfully with intent to defraud subscribes, makes, or concurs in making any annual or other statement required by law to be filed with the Commissioner containing any material statement which is false commits the crime of insurance fraud.
Vermont Fraud Advisement
VERMONT LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
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