Liability Claim Form « Lamb Financial Group

Liability Claim Form

Liability Claim | Property Loss | Workers Comp

The following information is required to submit a general liability claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Insured

Name:
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Email:

Type of Liability

If other please describe:
Type of premise / product: (business, residential property, etc:
Owner's Name:
Address:
City:
State:
Zip:
Phone:

Witness 1 Information

Name:
Address:
City:
Phone:
Remarks:
Reported by:

Occurence Information

Authority:
Location of Occurence:
City:
State:
Description of Occurence(be specific):

Individual Injured / Property Damaged

Owners Name:
Address:
City:
State:
Zip:
Phone:
Age:
Occupation:
Employer's Name:
Address:
City:
State:
Zip:
Describe Injury / Property (Type, Model, etc - BE SPECIFIC):

IMPORTANT:
In addition to submitting this form, you MUST send any and all additional information including:

- Police Reports
- Hospital Reports
- Internal Incident Reports

You may also print and fax this form for processing to:
718-389-4300

Lamb Financial Group

insurance designed for human service organizations

Liability Claim Form