Personal Liability Claims Form

SECTION 1: INSURED

SECTION 2: INCIDENT

SECTION 3: WITNESS

SECTION 4: POLICE

SECTION 5: TYPE OF LOSS/DAMAGE

SECTION 6: PERSONAL INJURIES (IF APPLICABLE)

SECTION 7: CLAIM

SECTION 8: DESCRIPTION OF INCIDENT

SECTION 9: DECLARATION

I/ We hereby declare that to the best of my/our knowledge the above statements are true.