File a General Liability Claim Step 1 of 2 50% Claim Reported By(Required)Email address Insured | Page 1 of 2NameOrganizationWork PhoneEmail Policy Number Loss Information | Page 2 of 2Date of Loss Month Day Year Location of OccurrenceDescription of OccurrenceNameAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneDescriptionDescribe injury/property damageCommentsEmailThis field is for validation purposes and should be left unchanged. If the form does not display, you may be using an unsupported browser (such as Internet Explorer). We suggest updating your browser. Visit this site to update your browser. Need a Different Form? Workers’ CompAutoProperty
