Liability Insurance Claim Form

The following information is required to submit a nonprofit liability insurance claim. This form should be used for General Liability, EPL, and Directors & Officers claims. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Insured
Type of Liability
Witness Information
Occurrence Information
Individual Injured / Property Damaged
Upload Claim Support Material
  • Upload any claim support material you have, such as Police Reports, Hospital Reports and/or Internal Incident Reports


    Clear uploads

    Accepted file extensions: .pdf, .doc, .docx, .png, .jpg

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