ISU Insurance Services - Meridian Brokerage: Liability Claim

Liability Claim

Name Of Insured:
Date Of Loss:
Time Of Loss:
Insurance Carrier:
Policy Number:
Policy Effective Date:
Contact Person:
Location Of Occurrence:
Description Of Occurrence:
Name And Address Of Injured Party:
Description Of Injuries To Other Party:
What Was Injured Party Doing?

If Damage Was Done To Property, Then:

Description Of Property:
Estimate Amount:
Where And When Property Can Be Seen:
Name, Address, And Phone Number Of Any Witnesses: