Dan Hurley Insurance

Independent Insurance Agent

General Liability Loss Notice

GENERAL LIABILITY LOSS NOTICE DATE(MM/DD/YY)
PRODUCER PRODUCER PHONE:
  
CODE: SUBCODE: COMPANY: POLICY NO:
POLICY EFF. DATE: POLICY EXP. DATE: DATE&TIME OF LOSS: PREVIOUSLY REPORTED(Y OR N):

Insured

NAME

ADDRESS:

 INSURED'S RESIDENCE PHONE: INSURED'S BUSINESS PHONE:
PERSON TO CONTACT: WHERE TO CONTACT: WHEN:
CONTACT'S RESIDENCE PHONE: CONTACT'S BUSINESS PHONE:

Loss
LOCATION OF ACCIDENT(city & state):
AUTHORITY CONTACTED:
DESCRIPTION OF ACCIDENT:

Type of Liability
PREMISES:INSURED IS OWNER TENANT OTHER  
TYPE OF PREMISES:
OWNER'S NAME & ADDRESS: OWNERS PHONE:
PRODUCTS:INSURED IS MANUFACTURER VENDOR OTHER
TYPE OF PRODUCT:
MANUFACTURER'S NAME & ADDRESS: MANUFACTURER'S PHONE:
WHERE CAN PRODUCT BE SEEN?: OTHER LIABILITY INCLUDING COMPLETED OPERATIONS:

Injured / Property Damaged
NAME & ADDRESS(INJURED/OWNER): PHONE:
AGE: SEX: OCCUPATION: EMPLOYERS NAME & ADDRESS PHONE:
DESCRIBE INJURY:   FATALITY: WHERE TAKEN: WHAT WAS INJURED DOING?
DESCRIBE PROPERTY(TYPE,MODEL,ETC.) ESTIMATE AMOUNT: WHERE CAN PROPERTY BE SEEN? WHEN?

Witnesses
NAME & ADDRESS: BUSINESS PHONE: RESIDENCE PHONE:

 

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