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Notification of
Liability Claim
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Please
note that this form is for a REQUEST ONLY.
By submitting this form it does not bind coverage in any way. If you do not hear from
us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST
FOR AN INSURANCE QUOTE, and call our office.
I understand
that filling out and submitting this form DOES NOT bind
coverage in any way, and the only way coverage can be bound will be when
I am informed of a binder or policy is issued by the agent representing
me.
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Insured's Name
(required) |
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Location of Occurrence:
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Description of Occurrence:
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Injured, Name, Address & Phone: |
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What was the Injured Party Doing?
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Describe Conditions of Premises:
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Property Damaged |
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Estimate of Damages |
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Witnesses, Name, Address, Phone:
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If Damage or Injury was Caused by a
Product, Describe Type of Product & Manufacturer:
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Comments:
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Reported By:
Date
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E-Mail:
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