Incident Report General Liability Property Automobile  
General Liability Notice
What to Report:
A reportable incident is any event which results in a loss, or may have caused a loss which under similar or slightly different conditions could result in serious injury or significant damage to personnel, assets, earnings, or general public.
  Contact Info 
  Name:
  Address:
  City:
  State:
  Zip:
  Phone:
  Email:
  Occurrence 
  Reported by:
  Date of Occurrence:
  Time of Occirence: AM  PM
  Date of Claim:
  Previously Reported: YES  NO 
  Location of Occurrence:
  Describe Occurrence:
  Insured 
  Name:
  Email:
  Address:
  City:
  State:
  Zip:
  Phone:
  Business Phone:
  Injured/Property 
  Injured Name:
  Address:
  City:
  State:
  Zip:
  Phone:
  Age:
  Sex: Male  Female 
  Occupation:

  Employer's Name:
  Address:
  City:
  State:
  Zip:
  Phone:

  Describe Injury:
  Where Taken:
  What was injured doing?
  Damaged Property:
  Estimate Amount
  Property can be seen at?
  When can it be seen?
  Witnesses 
  1
  Name:
  Address:
  City:
  State:
  Zip:
  Phone Number:
  2
  Name:
  Address:
  City:
  State:
  Zip:
  Phone Number:
  Comments 
  Comments: