General Liability Claim Form

The following information is required to submit a nonprofit liability insurance claim. This form should be used for General Liability, EPL, and Directors & Officers claims. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Fields marked with a red asterisk ( *) are required.

Sender Information
Type of Liability
Witness Information
Occurrence Information
Individual Injured / Property Damaged
  • You may also print and fax this form for processing to: (718) 389-4300