General Liability Claim - LIO Insurance

Loss Information
Property Damage*
- Yes
- No
Bodily Injury*
- Yes
- No
Other (Please specify)
Consent
Check box if reporting for record purposes only and no claim anticipated
Describe loss and damage (brief facts only); no conclusions as to liability or cause of loss*

Witness Information
Was there a witness?*
- Yes
- No
Witness Name
Witness Email Address
Witness Address 1
Witness Address 2
Witness City
Witness State
Witness Zip
Witness Primary Phone
Required Information: one of the following selections must be made*
- Please confirm reading and understanding of the fraud language and CA Consumer Privacy Act (CCPA) pertaining to the submission of this claim.
- If a broker or third-party representative is reporting this claim, please confirm sharing of this fraud language and CA Consumer Privacy Act (CCPA), which pertains to residents of respective states, with insured and/or claimant.
Reported By*
Email Address*
Name of Insurance Agent / Broker
Date Incident Reported to Association or Broker*
Attachment(s)
- Yes
- No
File
Max. file size: 50 MB.
Remarks
Please press the ‘Submit’ button and wait for your confirmation that the submission was received. Our claims department will be in touch within 24 hours.
Today's Date*
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