Report A Claim Step 1 of 2 50% Policyholder InformationType of Claim*Please Select...LiabilityPropertyAutomobileWorkers' CompensationAccident MedicalOtherPolicy Number*Time of Loss/Accident*If unsure, provide an approximate time.Date of Loss/Accident* Date Format: MM slash DD slash YYYY Insured's Company NameInsured's First & Last Name*Insured's Phone Number*Insured's Email* Enter Email Confirm Email Name of person completing this claim form.Relationship to the Insured (Venue, claimant, rental house, etc.) Or, Save what You've Entered So Far and Continue Later Liability Claim DetailsProperty Claim DetailsAutomobile Claim DetailsWorkers' Compensation Claim DetailsAccident Medical Claim DetailsClaim DetailsLocation name where claim/loss occurred*AddressCity, State, ZipContact PersonTelephoneProvide a detailed description of what happened*Provide as much detail as you can, including what authorities were contacted (Police, venue management, etc.). Provide police report # if applicable. In your opinion, do you think you are responsible for this claim? Explain.*Injured PersonsNames, Addresses, Telephone, Age, Sex and Occupation of all injured persons.Injured Employee Name, Address, Telephone, Date of Birth, Sex and Social Security numberInjured person's relationship to you (volunteer, employee, performer, spectator, etc.)What was person(s) doing when injury occurred?Describe InjuriesProperty DamagedDescribe the damage to the property.Name, address, telephone and email of property owner(s)Estimated amount of loss/damage.Where & when can property be seen?WitnessesIndicate name, address, and telephone numbers for all witnesses.Supporting DocumentsUpload any pertinent documents related to this claim. (Police Reports Incident Reports, Lawsuits, Medical Bills, etc.)Acceptable file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Maximum File Size: 128MB. Drop files here or Accepted file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. EmailThis field is for validation purposes and should be left unchanged. Or, Save what You've Entered So Far and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.