Customer Service Form:
General Liability Notice of Insurance/Claim

Please use the following form to notify our agency of a claim toward your policy. You will be contacted shortly by one of our representatives. This does not constitute a claim until confirmed by one of our agents.

POLICY HOLDER INFORMATION
Name of Insured:
Address:
Phone Number:	Home     Wk
E-Mail:
Insurance Company:
Policy Number:
TIME AND AND DESCRIPTION OF OCCURRENCE/CLAIM
Date of Loss:
Time of Loss:	a.m. p.m.
Location of Loss:
Description of Loss:
AUTHORITY NOTIFICATION
Were the police or fire department called?	yes    no
If yes, which authority?
REPORT INFORMATION
Reported by:
Title (if any):
Date:
ADDITIONAL COMMENTS Please give any additional comments you feel are appropriate for this Loss Notice.