Claim Form

Claim Form

Accident Information - General Liability

State Agency Involved*

Incident Date*

Incident Time*

Incident Location Address*

Incident Location City*

Incident Location County*

Description*

Police Authorities contacted?*

Yes

No

Accident Report Number

Claimant Information

Claimant Name*

Claimant Address, City, State, Zip Code*

Home Telephone*

Work Telephone

Claimant Date of Birth*

Social Security Number*

Injury Information

Was physical injury involved?*

Yes

No

Description of Claimant Injury

Fatality

Yes

No

Initial Treatment?

Yes

No

What initial treatment was given?

Treatment by Whom?

Hospital Treatment Needed?*

Yes

No

Name of Hospital

Witness Information

Any Witnesses?*

Yes

No

Witness 1 Name

Witness 1 Address

Witness 1 Telephone

Witness 2 Name

Witness 2 Address

Witness 2 Telephone

Witness 3 Name

Witness 3 Address

Witness 3 Telephone

Property Damage to Others Information

Brief Description of Claimant's Injury

Where is the property located now?

Damage to Claimant's Property

Repair Estimate

Comments

Your Name*

Your Telephone Number*

Send me a copy of my responses

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