Report a Liability Claim

Report a Claim

iPROTECT Insurance & Financial Services, Inc. — A Passion to Protect
Report any incident as soon as possible, even if you are not sure anyone will pursue it. Complete what you know. Questions? Call 256-444-2041.
LIABILITY CLAIM REPORT QUICK SHEET
IMPORTANT - WHAT TO DO AFTER AN INCIDENT
• Do NOT admit fault, promise payment, or discuss coverage with the claimant.
• Get medical help for anyone injured and call police if appropriate.
• Take photos of the scene, damage, and conditions before anything changes.
• Keep damaged items, video footage, and records. Do not discard evidence.
• Forward any letter, demand, or lawsuit papers to us IMMEDIATELY - deadlines are short.
INSURED & POLICY
Insured / Business Name
Policy Number
Insurance Company
Person Reporting

First NameLast Name
Title
Phone
Format: (000) 000-0000.
Email
example@example.com
INCIDENT DETAILS
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
Date Insured Learned of It

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location / Address of Incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Claim:
What happened? (describe the sequence of events, conditions, and what the claimant was doing)
CLAIMANT / INJURED PARTY
Claimant Name

First NameLast Name
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of Injury or Damage
Medical Treatment / Hospital
Est. Damage ($)
Is the claimant represented by an attorney, or have you received a demand letter or lawsuit?
WITNESSES & REPORTS
Witness Name

First NameLast Name
Phone
Format: (000) 000-0000.
Witness Name

First NameLast Name
Phone
Format: (000) 000-0000.
Police / Fire Dept. Responding
Report Number
Photos or Video Available? (Y/N)
Employee(s) Involved
Signature
Signature
Type your full name as your signature

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly presents false information, is guilty of a crime and may be subject to fines and confinement in prison. (State-specific notices may apply.)
Should be Empty:

Report a Claim

LIABILITY CLAIM REPORT QUICK SHEET

INSURED & POLICY

INCIDENT DETAILS

CLAIMANT / INJURED PARTY

WITNESSES & REPORTS

Signature