Commercial General Liability

If you are a policy holder you may use this form to submit a Commercial General Liability Loss . Please be sure to include as much information as possible.

Your Information
Insured's Name:
Address:
City:
State:
Zip/Postal Code:
Phone Number:
 
Description of Loss
Where did it occur?
Street Name:
Town/City:
When did it occur?
Date:
Time:

Description of Loss:

 


Other Party's Information
Owner's/Injured Party's Name:
Address:
City:
State:
Zip/Postal Code:
Phone Number:

Description of Injuries or Damaged Property:

 

Did the Injured Party Go to the Hospital?:
     

If yes, Name of Hospital:

Witness Information
Name:
Address:
City:
State:
Zip/Postal Code:
Phone Number:

Additional Comments: