ARM-Capacity General Liability Claim

HEADQUARTERS
90 Broad Street, Suite 1503
New York, NY 10004
Tel: 646.459.2400
TF: 888.276.6369
Fax: 212.937.3923

General Liability - Claim Form

The following information is required to submit a general liability claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Date of Occurence (mm/dd/yyyy)

Time of Occurence
am  pm

Date Claim was made (mm/dd/yyyy)

INSURED (how the policy is listed)

Name:

Address:

City State ZIP

CONTACT (insured contact information - i.e. owner, facility manager, etc.)

Name:

Home Phone:

Business Phone:

Cell Phone:

Email:

OCCURENCE INFORMATION

Authority Contacted: (Police, Ambulance, Fire Dept., etc.)

Location of Occurence:

City State

Description of Occurence (BE SPECIFIC):

TYPE OF LIABILITY (are you the owner, vendor, tenant, etc.)

Owner  Tenant  Manufacturer  Vendor  Other
If other please describe:

Type of premise / product: (business, residential property, etc.)

Owners Name:

Address:

City State ZIP

Phone:

INDIVIDUAL INJURED / PROPERTY DAMAGED

Name:

Address:

City State ZIP

Phone:

Age:
Sex:
Male  Female

Occupation:

Employer's Name:

Address:

City State ZIP

Phone:

Describe Injury / Property (Type, Model, etc - BE SPECIFIC):
If there was a fatality click this box

WITNESS 1 INFORMATION

Name:

Address:

City State ZIP

Phone:

Remarks:

Reported by:

IMPORTANT:
In addition to submitting this form,
you MUST send any and all additional information including:
- Police Reports
- Hospital Reports
- Internal Incident Reports
You may also print and fax this form for processing to:
212.937.3923