Liability Claim

Liability Claim Report

DO NOT ADMIT FAULT, LEAVE THE SCENE OR DISCUSS WITH ANYONE EXCEPT POLICE. CALL POLICE AND COMPLETE THE FOLLOWING INFORMATION:

* Denotes a mandatory fields (n/a if not available)

1. Policy Details

* Insurance Company

* Policy Number

* Claim Number

* Name of Agent/Broker

Home Phone

Home Fax

Policy Effective Date

Open the calendar popup.

Claim Date

Open the calendar popup.

Claim Time

Open the time view popup.

2. Insured Details

* Last Name

* First Name

* Home Phone * Other Phone

* Address

* City

* Province

* Postal / Zip

3. Police Fire Dept Information

Investigating Officer (Full Name)

Police /Fire Department to Whom Reported:

Station/Division

Badge No

Description of Damage/Accident (physical conditions):

4. Owner Information

* Owner of Property

Home Phone Other Phone

* Address

* City

* Province

* Postal / Zip

* Insurance Company

* Policy Number

Date of Damage/Accident

Open the calendar popup.

Time of Damage/Accident

Open the time view popup.

Hazardous Materials Involved?

select

5. Injured

Name of Injured

Home Phone Other Phone

Address

City

*Province/State

Postal Code/Zip

Extent Of Injury:

6. Witness Detail

Last Name

First Name

Home Phone Other Phone

Address

City

Province

Postal / Zip

7. Adjuster Details

Adjuster Name

Adjuster Phone Adjuster Ext

Company Claim Number

All losses should be reported directly to: Joel Carey of Partners Indemnity Brokers.

Business No.: (905) 336-1302
Mobile No.: (905) 876-6411
Facsimile: (905) 681-1054
E-mail: jcarey@csrm.ca

Liability Claim

Liability Claim Report

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