Notice of Loss · General Liability

General Liability claim form

This is the Gallagher Bassett Fax or Email Form, online. Fill in what you know; fields marked are required. When you finish, you'll get the completed PDF form and an email to claims@comeryx.com ready to send.

This form is for General Liability claims only. For a pollution liability claim, fill out the Spill or Pollution Incident Claim Form and have each witness fill out a Witness Statement.

Client information

GB Client Number042107

Client NameComeryx Insurance Services, Inc.

Date and time

Incident date

Insured notified date

Client location

The insured business location reporting this claim.

Policy Holder Business Name and DBA

Street address

City

State

ZIP

Phone number

Submitter information

The person filling out this form.

Name

Title

Email address

Phone number

Incident information

Detailed description of incident0 / 250

Location of incident

Where the incident happened.

Same as client location

Location name

Street address

City

State

ZIP

Authority

Police, fire department, or other authority contacted, if any.

Authority name

Phone number

Involved party

For additional parties, submit a separate form.

First name

Middle initial

Last name

Phone number

Birth date

Date of death (if applicable)

Street address

City

State

ZIP

Marital status

Gender

Relationship to client

Involved party employer

Employer name

Work phone

Occupation

Involvement type

WitnessesOnly if there were witnesses

Witness 1 first name

Witness 1 last name

Witness 1 home phone

Witness 1 work phone

Witness 2 first name

Witness 2 last name

Witness 2 home phone

Witness 2 work phone

Medical providerOnly if medical treatment was given

Hospital / clinic name

Hospital / clinic phone

Street address

City

State

ZIP

Doctor name

Doctor phone

Street address

City

State

ZIP

PropertyIf property was damaged

Third-party property?

Estimated damage ($)

Insurance company name

Policy number

Describe item(s)

Damage description

Where the property can be seen

Name

Owner

When

Street address

City

State

ZIP

Contact information

Who the adjuster should contact about this claim.

First and last name

Phone

Notes / additional comments

For example, if this is for report only.

Additional remarks