Lemark Insurance Agency, Inc.
General Liability Notice Of Insurance/Claim
  
 General Liability Notice Of Insurance/Claim
Please use the form below to notify our agency about a claim towards your policy. You will contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.
 

Policy Holder Information
Name Insured:
Address:
Phone #: Work     Home
Email:
Insurance Company Name:
Policy Number:

Time and Description of Occurrence/Claim
Time & Date of Loss
Time a.m.
p.m.		     Date
Location of Loss:
Description of Loss:

Authority Notification
Were the Police or Fire Dept. Called? Yes     No
If Yes, which Authority?

Report Information
Reported by:
Title (if any):
Date:


Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice. Including description of injury, property, & witnesses.