Liability Claim :: First Report Form

In addition to filling out the form below, the original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.

Information About Our Insured
Name of person who makes a claim against you
Person to contact for claimant
Incident / Injury Information
Describe property damage (type, model, etc.)
(in dollars)
Where property can be seen by company adjuster
Form Verification (this proves you're not a robot!)

This website provides a general summary of the insurance coverages that you should consider. It is interpretive only and is not intended to replace or supersede any of the terms and/or conditions of the policies comprising the insurance program. In case of specific interpretation of coverages, you need to refer to the actual policies. Please Note: You cannot contract for coverage by means of e-mail or by requesting information or coverage through this website. Coverage will only become effective after your account has received approval by the insurance company and a deposit premium is received in our office.