GENERAL LIABILITY ASSIGNMENT
 From  Company
 Date of Occurance  Time of Occurance  Claim #  Date of Claim
 Insured  Phone (H)  (W)
 Address  City  ST  Zip
 Contact  Phone (H)  (W)
 Address  City  ST  Zip
 Where to Contact  When to Contact
 Location  Authority Contacted
 PREMISES
 Insured is Owner Tennant Other		  Type of Premises
 Owner  Phone (H)  (W)
 Address  City  ST  Zip
 PRODUCTS
 Insured is Manufacturer Vendor Other		  Type of Product
 Manufacturer  Phone (H)  (W)
 Address  City  ST  Zip
 Where can this product be seen?
 Other Liability Including Completed Operations (explain):
 
 Injured Name  Phone (H)  (W)
 Address  City  ST  Zip
 Date of Birth  Age  Sex  Occupation
 Employer Name  Phone (H)  (W)
 Address  City  ST  Zip
 Describe Injury
 Where was injured taken?  What was injured doing?
 Describe Property
 Estimate Amount  Where Property can be Seen  When Property can be Seen
 Name & Address  Home Phone  Work Phone
     
     
     
Type
Full Investigation
Limited Investigation
Special Instructions
INTERVIEW
Insured_Owner
Claimant
Witnesses
Other
SECURE
Report: CHP/Police/OSHA/Fire/Other
Photograph Scene/Damage
Appraisal
Medical Authorization
Medical Records
Remarks
 Reported By:
 Date of Assignment:  Due Date: