General Liability Claim Form
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Agent Information Section
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Insured Information Section
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Please provide at least one of the following
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Contact information (if different from named insured)
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Loss Information Section
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Description of Occurrence:* |
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Additional Comments if Any: |
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Type of Liability Information Section
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Injured/Property Damaged Section
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Witness Information Section
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Reporting Information Section
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If not reported by our insured, complete the information below |
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