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General Liability Claim Form
General Liability Claim Form
First Notice of Incident General Liability Information Sheet
Are you insured by Neace Lukens?
*
Yes
No
If yes, list agent name or Neace Lukens office location:
Insurance Company:
*
Policy Number:
*
Date Reported:
*
Insured/Your Company Name:
*
Contact:
Phone:
(Contact)
Reported By:
Phone:
(Reported By)
Check One:
Report as a claim
Report as information only
Incident Date/Time:
*
AM
PM
Incident Location:
(Street Address, City, State, County)
*
Characters Remaining: 1000
Incident Description:
(What happened)
*
Characters Remaining: 1000
Customer or Person Involved (not an employee)
Name:
Address:
Phone:
(daytime)
Phone:
(mobile or other)
Type of injury:
Where taken:
Property damaged:
Estimated amount of property damage:
$
If injured person was working for another employer at the time of the incident, add info below
Employer Name:
Employer Address:
Employer Contact:
Employer Phone:
Product or Equipment Involved
Product Name:
Purchased From:
Phone:
(Purchased From)
Manufacturer Name:
Phone:
(Manufacturer)
Witness
Witness Name:
Phone:
(Witness)
Police
City/County/State:
Report #:
Phone:
(Police)
*
= required field