General Liability Claim Form

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

Sender Information
Type of Liability
Witness Information
Occurrence Information
Individual Injured / Property Damaged
Upload Claim Support Material
  • Upload any claim support material you have, such as Police Reports, Hospital Reports and/or Internal Incident Reports

    Clear uploads

    Accepted file extensions: .pdf, .doc, .docx, .png, .jpg

  • You may also print and fax this form for processing to: 1-332-777-1286