NOTICE OF LIABILITY CLAIM Today's Date: From: Company: Phone: Fax: *Date of Accident: *Location of Loss: *Description of Loss Insured Information: Liability: Premises: Insured is Owner   Tenant Owner's name (if not insured) Address City State Zip Products: Insured is: Manufacturer  Vendor  Other Manufacturer's name & address (if not insured) Where can the product be seen? Claimant Information Injured/Property Damaged: Name: Address: City: State: Zip: Home Phone: Business Phone: Describe Injury/Property Damaged: Where can property be seen: Witnesses: Name Address City State Zip Phone: Name Address City State Zip Phone: Remarks:

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