An unexplained error has occured. Please use your browser's button and try again. General Liability Notice Of Insurance/Claim Please use the form below to notify our agency about a claim towards your policy. You will contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents. Policy Holder Information Name Insured: Address: Phone #: Work Home Email: Insurance Company Name: Policy Number: Time and Description of Occurrence/Claim Time & Date of Loss Time a.m. p.m. Date Location of Loss: Description of Loss: Authority Notification Were the Police or Fire Dept. Called? Yes No If Yes, which Authority? Report Information Reported by: Title (if any): Date: Additional Comments Please give any additional comments you feel appropriate for this Loss Notice. Including description of injury, property, & witnesses.