Liability REPORT A BUSINESS LIABILITY CLAIM For all other carriers, please complete the form below.Please enter the insured’s personal information so we can look up your policy and contact you regarding your claim. Name of Insured:(required) Mailing Address #1:(required) Mailing Address #2: City:(required) State:(required) Zip Code:(required) Policy Number: Who should we contact regarding this claim? Contact Name:(required) Contact Phone:(required) Contact Email:(required) How should we contact you? Email Phone Please provide us with some information about the property damaged: Name of Injured/Owner of Property:(required) Address: City: State: Zip: Phone Number:(required) Please provide us with some information about the accident: Location of Accident:(required) Description of Accident:(required) Terms: This claim cannot be considered filed under the notification guidelines of your policy unless you receive a reply from our firm. If you haven’t received a reply within 48 hours, please contact us via phone. If you have any additional paperwork, please fax to Robin Roberts at 706-883-8915 after submitting this form.