First Notice of Loss Form - General Liability
To submit a New Assignment, please complete this form below and click on the Submit button. Please enter as much information as possible to expedite the investigation process. If you have any questions, please call (888)799-2919.
Required fields are in bold and noted with a *
* Reported By:
* Phone, (xxx) xxx-xxxx:
Insured Information
* Name: (First)
* (Last)
* Policy Number
Address:
City:
State:
Zip Code:
* Primary Phone, (xxx) xxx-xxxx:
Alternate Phone:
Contact Information
Name: (First)
(Last)
Address:
City:
State:
Zip Code:
Primary Phone, (xxx) xxx-xxxx:
Alternate Phone:
Loss Information
* Date of Loss (MM/DD/YYYY):
Time of Loss (xx:xx):    
*Location of Loss:
City:
State:
* Description of Claim and Damage:
Person Injured / Property Damaged
Person Injured's Name:
Address:
City:
State:
Zip Code:
Residence Phone, (xxx) xxx-xxxx:
Business Phone:
Age:
Sex:
Occupation:
Fatality:
Where was the Claimant taken?
What was the Claimant doing?
Property Damaged:
Estimate:
Where and When can property be seen?
 
Notes/Remarks: