Sterling & Serling: Secure Form

Liability Claim

* = required field

Date of Occurence (mm/dd/yyyy)


Time of Occurence
 am  pm
  Insured

Name*:


Address:


City State ZIP
  Contact

Name:


Home Phone*:
 

Business Phone:
 

Cell Phone:
 

Email:
  Occurrence

Authority Contacted:


Location of Occurence:


City State
Description of Occurence:
  Type of Liability

Premises / Products:
Owner  Tenant  Manufacturer  Vendor  
Other

If other please describe:


Type of premise / product:


Owners Name:


Address:


City State ZIP

Phone:
 
  Injured/Property Damaged

Name:


Address:


City State ZIP

Phone:
 

Age:
 Sex:
Male  Female

Occupation:


Employer's Name:


Address:


City State ZIP

Phone:
 

Describe Injury / Property (Type, Model, etc):
Fatality
  Witness

Name:


Address:


City State ZIP

Phone:
 

Remarks:


Reported by: