Liability Claim Form

Name*

First NameLast Name

Date of Birth

MonthDayYear

Phone Number*

Please enter a valid phone number.

Email (to receive a copy of this form)

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date and Time of Incident*

Date

Hour MinutesAM/PM Option

Weather conditions:*

Description of incident, including the location*

Was the incident reported to the police?*

YesNo

Police Report # (If known)

Are you claiming property damage?*

YesNo

Please describe what was damaged and how the damage was occurred. *

Are you claiming bodily injury?*

YesNo

Please describe what body part was injured and the nature of the injury and how it occurred.*

Please upload any receipts, images and other documents related to your claim.

“Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, Florida Statutes.”