General Liability Claim Form

   Back to CLAIM FORMS Page Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  
ALL RIGHTS RESERVED

General Liability Claim Form

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-  This form is intended for General Liability Claims.  If your claim involves an Auto, use the Auto
    Claim Form.  If your claim involves your "owned" property, use the Property Claim Form.

Your Account Name:

 Phone: Type: Cell  Business  Home

City, State

State:

 Fax:

Person Completing Form:

 Email:
 THIS CLAIM IS:
   An Actual Claim whereas you have received a bill, suit, call, or formal notice seeking collection for damages
   for Reporting Purposes Only, whereas it could develop into the above
 WHO IS TO BE LEAD CONTACT FOR FURTHER INVESTIGATION OR CLAIM INFORMATION     SAME AS ABOVE OR COMPLETE
 Lead Contact Name:   Phone #:Cell  Business  Home    Email:
 CLAIM INFORMATION
 Date of Claim Occurrence:   Time of Claim Occurrence: AM  PM
 Location of the Claim (address, city, state, zip or specific area):
 Description of what happened?
 If an authority such as police, fire, medical was contacted, please name:
 What is the report # of the authority, if known:
 INJURED PERSON OR INFORMATION FOR OWNER OF DAMAGED PROPERTY
 Is this a notice of an    INJURY / FATALITY   and/or    PROPERTY DAMAGED
 Named of injured person or name of owner of damaged property:
 Address of above (incl. city, state, zip if known):
 Sex: Male   Female         Age (approx. if not known):       Phone #:
 Occupation of Injured Party or owner of damaged property: or Not Known
 Description of Injury or Damaged Property:  or  Fatality
 If damaged property, where can property be seen:   or   Unknown    Call Owner
 AMOUNT OF DAMAGES
 Estimate Amount of Damages ($ Amount):  or   Unknown
 WITNESSES
    No Witnesses         Numerous Witnesses (too many to list all)
 Schedule of Individual Witnesses if neither check off box above is appropriate
 1. Name:  Address:   Phone:
 2. Name:  Address:   Phone:
 3. Name:  Address:   Phone:
 ADDITIONAL NOTES / COMMENTS


 
!!!  IMPORTANT  !!!
 
If serious Bodily Injury or a Fatality has occurred, please click on the link HERE and review the document.  The document will open in a separate browser window so this browser window remains open and unchanged.  This document is informative information on steps / procedures that could be followed in the event of a claim.

 For Outfitters & Guides Insurance
 1. Secure the claimant's "Signed" Waiver / Release of Liabilty form. Keep in safe place.
 2. Secure the equipment that could be construed as part of the claim?
 3. Have employee / guide complete an incident report. Sample Report, click HERE

 Supporting documents above can be held until your company adjuster requests them.
 

QUESTIONS / HELP

 

Office Email:

 insurance@thompsongusic.com

Office Phone:

 (412) 271-8888  (9 - 4:30 EST)

Office Fax:

 (877) 271-8898

 

 CREATED 6/00 by
T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: September 04, 2019 .