Liability Claim Report - Brown & Brown Garden City

Company Name (if applicable)

Your Name

First Last

Insured Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's contact names & numbers

Describe incident - what occurred and how?

Location of Loss

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Loss

Claimant's Name

First Last

Claimant's Age

Claimant's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claimant's Phone

Describe any injuries or illness

Witnesses - Name, Address and Phone Number

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