Liability and Other Incidents

File a Liability/Other Incidents Claim

Complete the form below to send us your initial claim or incident report. Sections marked with an (*) are required. At the bottom of the page, you are able to upload documents and photos related to your claim. We will follow up with you soon after the report is submitted and received. Please always feel free to contact us at 800-882-0801. Thank you.

Incident Report Form
Name*
First Last
Phone Number*
Email*
Date of Incident*
Month
Day
Year
Time of Incident

: Hour

Minute

AM/PM
Your Department/Organization Name*
Location of Incident*
Incident Details
Was a Police Report Filed?
- Yes
- No
- N/A
If Yes, Enter Police Department Name
Police Report Number
Incident Description: Describe the incident and include any additional information you think we should know. We'll reach out to you with any questions.*
Upload Photos and Documents
Use this section to upload any photos or documents related to this claim. If you're using a mobile device, you can easily snap photos with your smartphone after clicking any of the 'Choose File' buttons below. We accept photos of all documents including police reports.
Upload File(s)
Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Click below to submit your report. We will follow up with you asap.
Name
This field is for validation purposes and should be left unchanged.

Liability and Other Incidents

Liability and Other Incidents

File a Liability/Other Incidents Claim

Incident Report Form

Incident Details

Upload Photos and Documents

Click below to submit your report. We will follow up with you asap.