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
and noted with a *
* Reported By:
* Phone, (xxx) xxx-xxxx:
* Name: (First)
* Policy Number
* Primary Phone, (xxx) xxx-xxxx:
Primary Phone, (xxx) xxx-xxxx:
* Date of Loss (MM/DD/YYYY):
Time of Loss (xx:xx):
*Location of Loss:
* Description of Claim and Damage:
Person Injured / Property Damaged
Person Injured's Name:
Residence Phone, (xxx) xxx-xxxx:
Where was the Claimant taken?
What was the Claimant doing?
Where and When can property be seen?