Welcome to Jack Rice Insurance, Florida Trusted Choice Insurance for Boats and fine art, Homeowners, Auto, Commercial, Life and more. Located on the west coast of Florida. We serve you first.

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:

Direct Reporting Companies
Property
Liability