Summit Insurance - General Liability Accident Form

General Liability Accident Form

This is a claim form. Please enter the information requested below. All fields are required unless otherwise noted.
If you would like a printable form that you can mail or fax to us, please choose a version to download: English Spanish


Name of Person Completing Report				Email Address			Verify Email Address
Company Name, Address, City, State, Zip							PO or Job #
Accident Location							Date of Accident
Employee Most Knowledgeable about Accident							Time of Accident, AM or PM

Property Damage or Injury Information
Name, Owner or Injured
Address				City			State	Zip
Phone 1					Phone 2 (Optional)
Birthdate				Age	Social Security Number
Check all that apply:
Male	Female	Single	Married	Divorced	Widowed	Employed	Retired	Student	Property Only
Complicating Medical Conditions: ie. diabetes, high blood pressure, asthma, etc.
Heavy Equipment Involved			Driver			Used with Permission: Yes No		Insured Damage

Accident Information
Date you were made aware of claim			Claim is:
			Property Damage	Bodily Injury	Insured Damage	Medical Payments	Theft	Fire	Product
Accident Description
Witnesses
Authority Contacted					Violations
Report Number
Is this a questionable accident? Yes No				Estimate of Damages (Enter Dollar Amount) $
Subrogation: Is any person, company or machinery responsible for injury? Yes No					If you answered Yes to the last question, please give details:
Any Additional Information