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» General Liability

Worker's Compensation

Disability

Your insurance policy requires that you see to it that they are notified as soon as practicable of any “occurrence” or an offense which may result in a liability or third party claim. To the extent possible, notice should include:

  • How, when and where the “occurrence” or offense took place
  • The names and addresses of any injured persons and witnesses and
  • The nature and location of any injury or damage arising out of the “occurrence” or offense. If a claim is made or “suit” is brought against you, you should record the specifics of the claim or “suit” and the date received and notify us as soon as practicable. You should immediately send copies of any demands, notices, summonses or legal papers received in connection with the claim or “suit” and cooperate fully in the investigation of the claim.

Do NOT voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without the insurance carriers consent. You may use the form below to report a potential liability claim or call our claims office on 516-766-3513 ext. 102.

GENERAL LIABILITY NOTICE OF OCCURRENCE

   INSURED
Name of Insured:
Address:
City:
State:
Zip:
Contact Name:
Phone:
Alternate Phone:
Email Address:

  OCCURRENCE
Date of Occurrence: (MM/DD/YYYY) 
Time of Occurrence: (HH:MM)
Location of Occurrence:
(Include City and State)

  INJURED/PROPERTY DAMAGED
Name of Injured Party:
Address:

State:

 Zipcode:
Describe Injury:
Where Taken:
Describe Property:
(Type, Model, etc.)
Where can property be seen:


You will receive Email confirmation of your claim within 24 hours. We will contact you if further information is required. If you do not receive confirmation that your claim was received please call our Claims Department on 516-766-3513 ext. 102

 
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