General Liability Claim Form

Incident Details

Use this form to report incidents affecting members of the general public or others while on your property which you believe could reasonably result in a claim against you. Do not use for Auto Accidents or Worker's Compensation claims.

When describing the incident, please use as much information as possible. For example:

  • When reporting a slip and fall incident - Was the claimant wearing sunglasses? What type of shoes, kind of soles? Does claimant have any handicaps or disabilities? Was s/he on medication? What kind of surface was claimant walking on? What was the lighting condition? Was the surface wet or dry? Any debris present? Any defects? Surface irregularities?
  • For stolen items, were they secured? What kind of lock was used? Who has the keys or access? Supply brand name, original cost, date of purchase?
  • For damaged personal property, give brand names, original cost, date of purchase, where can it be seen?
  • For broken furniture, was item removed from circulation? Was it stored for examination by investigator? Where stored? (Do not repair or discard broken items involved in a claim until told to do so by Adjuster)

Injury Information

Use this form to report incidents affecting members of the general public or others while on your property which you believe could reasonably result in a claim against you. Do not use for Auto Accidents or Worker's Compensation claims.

If there are no injuries, please move onto the next step of the form.

Property Damage Information

Use this form to report incidents affecting members of the general public or others while on your property which you believe could reasonably result in a claim against you. Do not use for Auto Accidents or Worker's Compensation claims.

If there is no property damage, please move onto the next step of the form.

Documentation

Use this form to report incidents affecting members of the general public or others while on your property which you believe could reasonably result in a claim against you. Do not use for Auto Accidents or Worker's Compensation claims.

When adding documentation, please be sure to upload original copies when possible. Photocopies are rarely adequate.

If you have no documentation for upload, move on to the next step of the form.


Contact Information

Use this form to report incidents affecting members of the general public or others while on your property which you believe could reasonably result in a claim against you. Do not use for Auto Accidents or Worker's Compensation claims.