General Liability Assignment Form

General Liability Assignment

 From    Email    Company  
 Date of Occurance    Time of Occurance    Claim #    Date of Claim  

 Insured    Phone (H)    Phone(W)  
 Address    City    ST    Zip  
 Contact    Phone (H)   Phone(W)  
 Address    City    ST    Zip  
 Where to Contact    When to Contact  

 Location  Authority Contacted


 Insured is Owner Tennant Other
 Type of Premises  

 Owner    Phone (H)    Work Phone (W)  
 Address    City    ST    Zip  


Insured is Manufacturer Vendor Other
 Type of Product  

 Manufacturer    Phone (H)    Work Phone (W)  
 Address    City    ST    Zip  
 Where can this product be seen?  
 Other Liability Including Completed Operations (explain):

   Injured Name    Phone (H)    Work Phone (W)  
 Address    City    ST    Zip  
 Date of Birth    Age    Sex    Occupation  
 Employer Name    Phone (H)    Work Phone (W)  
 Address    City    ST    Zip  
 Describe Injury  
 Where was injured taken?    What was injured doing?  
 Describe Property  
 Estimate Amount    Where Prop can be Seen    When Prop can be Seen  

 Name & Address  Home Phone  Work Phone


 Full Investigation 
 Limited Investigation 


 Insured Owner 


 Report: CHP/Police/OSHA/Fire/Other 
 Photograph Scene/Damage 
 Medical Authorization 
 Medical Records 


 Reported By:

Date of Assignment:


90-Day Discovery Period Ends: