Century Insurance Group
General Liability Loss Notice

Fraud Statement - Applicable in All States:
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.


** Required Fields

Agent Information

Name:

Phone Number:
 

Address:
 

City: 

State: 

Zip:
 

Insured Information

Insured's Name:
 **

Address:
  **

City: **

State: **

Zip:
**

Contact Person:
  **

Address:
  **

City:
**

State:
**

Zip:
**

Primary Phone Number:
  **

When to Contact:
**

Secondary Phone Number:
 

Where to Contact:
**

Policy Information

Company: 

Policy Type: **

Effective Date:  **

Expiration Date:
**

Policy Number:
**

Coverage Part or Forms  (include edition date): 

General Aggregate:

Prod/Comp Op Agg:

Pers & Adv Inj:

Medical Expense:

Fire Damage:

Excess Carrier:

Each Occurrence:

Deductible:  $  

UMB/Excess Limits:      AGGR      PER CLAIM          PER OCC 

Claim Information

Date of Loss:
  **

Location of Loss:
  

Authorities Notified:

If Yes, Whom:
 

Description of Accident: 
  **

If Premise Claim, Insured Is?
  If Other, please specify:

Type of Premises:
 

Owner's Name: 
 

Phone Number:
 

Address:
 

City: 

State: 

Zip:
 

If Products Claim, Insured is?
  If Other, please specify: 

Where Can Product Be Seen:
 

Claimant / Property Damage Information

Name (Injured/Owner):
 

Phone Number:
 

Address: 

City:
 

State
 

Zip:
 

Age: 

Sex:
  

Occupation:
 

Employer's Name:
 

Phone Number: 
 

Address:
 

City:
 

State:
 

Zip:
 

Describe Injury or Property Damage:
 

Hospital / Where can Property be seen?
 

Witnesses Information

Name: 

Primary Phone:  

Secondary Phone:  

Address: 

City:  

State:  

Zip:  

Name: 

Primary Phone:  

Secondary Phone:  

Address: 

City:  

State:  

Zip:  

 Remarks
 

Reported By:
  **

Lawsuit Filed: