Conrey Insurance - General Liability Loss Notice Form

GENERAL LIABILITY NOTICE OF INSURANCE/CLAIM

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

Policy Holder Information

Insured First Name:

Insured Last Name:

Address:

Phone #: Work Home

Email:

Insurance Company Name:

Policy Number:

Time and Description of Occurrence/Claim

Time & Date of Loss

Time

a.m.
p.m.

Date

Location of Loss:

Description of Loss:

Authority Notification

Were the Police or Fire Dept. Called? Yes No

If Yes, which Authority?

Report Information

Reported by:

Title (if any):

Date:

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice. Including description of injury, property, & witnesses.