General Liability Claim

Please fill out the form below (or) print and fax our PDF form to 617-964-3256.



* Required fields

Date of Loss and Time *
Policy Number *
Please Enter Your Full Name (First, Middle, Last) *
Please Enter Your Email Address *
Name of Insured (Enter Company Name) *
Location of Occurence (Street, City & Zip) *
Named Insured Contact *
Named Insured Contact Phone Number *
Named Insured Contact Email Address *
Description of Occurence *
Was ther any resulting property damage or injuries? *	Yes No
If yes to above, please provide a brief description
Where There Any Witnesses? *	Yes No
If yes to above, please provide names and contact information for each witness
Remarks/Additional Information

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