River Crest Insurance | Liability Claim Notice

Notice of Liability Claim

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

General Information
Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Best Time To Contact:
Contact By:
Insurance Company:
Policy Number:

Liability Information
Premises: Insured is:
Owner's name (if not Insured):
Owner Address:
Owner City:
Owner State:
Owner Zip Code:

Products: Insured is:
Manufacturer's name (if not Insured):
Manufacturer Address:
Manufacturer City:
Manufacturer State:
Manufacturer Zip Code:
Where can product/property be seen?:

Claimant Information Injured/Property Damage
Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:

Incident/Accident Information
Time of Loss
Date of Incident:
Location of Loss:
Detail Description of Injury/Property Damage:
Please list any witnesses their contact information: i.e. Name (email address/phone); Name 2 (email address/phone)

Additional Information In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.