general liability

General Liability

Insured Name *
Contact Person
Insured Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Center Name (if applicable)
Phone *
Fax
Email *
Policy Number
Accident / Injury Information
Date of Accident *
MM / DD / YYYY
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 there were witnesses, provide contact information
Report completed by
Daytime Phone