Reporting General Liability Claims Guide
Account Information
Provide Company Information if applicable
Product Liability
Provide location of your Company Headquarters
Slip and Fall or Other Liability
Provide location where accident occurred
All Liability Claims
Your Business name & address (include specific division if applicable
and mailing address if different than above.
Specifics e.g. aisle of fall, Dept.
Accident Information
Date & time of accident
Detailed description of accident
Product Liability
Product information
- how was product being used
- specify manufacturer's name
- make/model/size/style/serial # and/or product I.D.
- was there damage to product
- where & when purchased
- where & when can product be seen
IMPORTANT!
SAVE THE PRODUCT INVOLVED FOR INSPECTION
DO NOT DESTROY
Slip and Fall
What substance or object did claimant slip/trip or fall on (if any)
How did substance or object get there
All Liability
Witnesses including specifics on where they were at time of accident,
any relationship to involved parties and means of contact (address, phone
#, best time & place)
Authorities (ambulance, police, fire) include address, report # and any violations/citations that may have been issued
Nature of Occurrence Were there complaints of injuries (any special
treatment)?
Was there any damage to property you don't own?
- If yes, refer to info needed in "property damage" section
Injuries
Name, address, home & business phone for injured
Occupation (if provided)
Date of birth (age) Social Security # & sex
Description of injury
Was medical treatment received? If so, from who
- Name, address, phone # of hospital/clinic/doctor
- Type of treatment, length of stay, specialty of doctor
- First day of treatment
Is injured represented by an attorney
- Name, address & phone number
- Was lawsuit served? If yes, date of service
Employer Information (Name, address & phone) (If multiple injuries, repeat above section)
Property Damage Information
Property owner's name, address, home and business phone
Description of damage (include both description of item and damage to
that item)
Estimate of damage, if available (If other property damage, repeat above section)
Account Contact Information
Best person (including time & place) to contact for more information
Additional comments and information