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By using this service, you can expedite the handling of your claim.  After you complete the notice, it is sent electronically to the appropriate claims department personnel who will contact you within 24 hours.  For more information visit the Claim Notification Center.

General Liability

 
    required  Denotes Required Fields
Contact Information
Name of Person to Contact required
Email Address of Person to Contact required
Phone Number of Person to Contact required  -  -

Person Reporting Claim required
Phone Number of Person Reporting Claim required  -  -

Email Address of Person Reporting Claim required
Policy Profile Policy Number  
Policy Holder Name (individual or company) required
Policy Holder Street Address  
Policy Holder City  
Policy Holder State required
Policy Holder Phone    -  -

Loss Location Street Address required
City
State
Zip  
Loss Location Code  
Description of Loss Date of Loss required
Description of Loss required
Claimant Name required
Claimant Phone #  -  -

Claimant Address
Claimant Email
Property Damage? required
If Yes, Estimate of loss? required
Bodily Injury required
Other Injury required
Reported to the Police? required
If Yes, Police Department and Case Number required
Suit Information Has Suit been filed? required
If Yes, Date Served required
Venue  
File Attachments  
Following packages will be used to scan file(s):
* McAfee VirusScan Enterprise
Allowed file types:
  .doc .docx .pdf .jpg .jpeg .gif .bmp .png .tif .rar .zip .xls .xlsx

File size is limited to 3 (MB) per file. Maximum Files: 5 
Submit Claim Form Here
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