GENERAL LIABILITY INCIDENT REPORT
Complete this form if a non-employee is injured. When authorized, report claims toyour insurance carrier or Sweet Insurance. Do not delay reporting the claim because you do not have all the information regarding the incident. Additional information can be provided at a later date. Enter multiple forms for more than one Claimant.
Incident Information - General Liability
Insured Name:
First Name
Last Name
Policy Number (if known):
Date of Incident:
*
-
Month
-
Day
Year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Incident Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Incident:
*
Were the authorities contacted?
*
Yes
No
If yes, Incident Report Number:
Police Department Contacted:
Police Department Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claimant Information
Claimant Name:
First Name
Last Name
Claimant Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claimant Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Injured Party DOB:
-
Month
-
Day
Year
Date
Injured Party Age:
Injured Party Email Address:
example@example.com
Injury Information
Description of Claimant's Injury:
Was treatment given?
Yes
No
If yes, treatment was given by whom?
Was hospital treatment needed?
Yes
No
If yes, which hospital?
Was there a fatality?
*
Yes
No
Witness Information
Were there any witnesses?
Yes
No
Witness Full Name:
First Name
Last Name
Witness Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Witness Email:
example@example.com
Property Damage To Others Information
Claimants Vehicle Involved (year, make, model, VIN, etc.)
Where is the vehicle located now?
Damage to claimant's property (building/home)?
Repair Estimate Amount:
Report Completed by (your name):
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Submit
Should be Empty: