General Liability Accident Information Form

Note: BOLD indicates required field

CONTACT INFORMATION

Insured Name:
Contact Person:
Insured Address:
City:   State:   Zip:
Center Name (if applicable):
Phone:   Fax:
E-mail:
Policy Number:

ACCIDENT / INJURY INFORMATION

Date of Accident:
Time of Accident:
Location of Accident:
Description of Accident:
Did anyone require medical
attention at the scene?		 Yes  No
If so, provide Name, Address, Phone Number and Extent of injuries:
Was person taken to hospital
or emergency facility?		 Yes  No
If so, which?
Was property damaged? Yes  No
If so, provide Name, Address, Phone Number and Description of Damage:
 
If there were witnesses, provide contact information

 
Report completed by:
Daytime Phone:

 

 

 		  


 

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