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General Liability Notice

Date of Accident	Time am pm
Policy Number

INSURED & CONTACT INFORMATION
Insured Name
Address
City, State Zip	,
Residence Phone
Business Phone

Contact Name
Contact Address
City, State Zip	,
Where to Contact
When to Contact
CONTACT INFORMATION
Contact Name
Contact Address
City, State Zip	,
Where to Contact
When to Contact

OCCURRENCE
Location of Occurrence
City, State	,
Authority Contacted
Report #
Description of Occurrence
TYPE OF LIABILITY
Premises: Insured Is	Owner Tenant Other
If Not Insured
Name
Address
City, State	,
INJURED/PROPERTY DAMAGED
Injured/Owner's Name
Injured/Owner's Address
City, State	,
Residence Phone
Business Phone
Injured/Owner's Age	Sex
Occupation
Description of Injury	Fatality Yes No
Where Taken
What was injured doing?
WITNESSES
Name
Address
City, State Zip	,
Residence Phone
Business Phone
SUBMITTED BY:
Name
Agency
Address
City, State	,
LOC Code
Date of Claim
Agent Notes
Phone
Fax
Email

IMPORTANT NOTICE: On-line claim reporting forms are submitted to Irwin Siegel Agency, Inc. If form is submitted after business hours or on a weekend, it will be sent to the carrier for processing the next business day (Monday through Friday 8:00 a.m. - 4:30p.m.)

General Liability Notice

INSURED & CONTACT INFORMATION

CONTACT INFORMATION

OCCURRENCE

TYPE OF LIABILITY

INJURED/PROPERTY DAMAGED

WITNESSES

SUBMITTED BY: