Diamond State Group


	GENERAL LIABILITY NOTICE OF OCCURRENCE/CLAIM Complete the form below then click Submit.

I am the:

Date (MM/DD/YYYY):

Agency:

Address:

City:

State:

Zip Code:

Phone (A/C, No, Ext):

Fax (A/C, No):

E-Mail Address:

Notice of OccurrenceNotice of Claim

Date of Occurrence:

Time of Occurrence:

AM/PM:

Date of Claim:

Previously Reported:

Policy Type:

Effective Date:

Expiration Date:

Retroactive Date:

Company

Policy Number:

INSURED

Insured Name:

Address:

City:

State:

Zip Code:

Res. Phone (A/C, No):

Bus. Phone (A/C, No, Ext):

E-Mail Address:

Soc Sec # or FEIN:

CONTACT

Contact Insured

Contact Name:

Address:

City:

State:

Zip Code:

Res. Phone (A/C, No):

Bus. Phone (A/C, No, Ext):

E-Mail Address:

Where to Contact:

When to Contact:

OCCURRENCE

Location of Occurrence:

City:

State:

Authority Contacted:

Description of Occurrence:

POLICY INFORMATION

Coverage Part or Forms (Insert form #s and edition dates):

General Aggregate:
$

Prod/Comp Op Agg:
$

Pers & Adv Inj:
$

Each Occurrence:
$

Fire Damage:
$

Medical Expense:
$

Deductible:
$

PDBI

Umbrella/Excess:

TYPE OF LIABILITY

Premises:
Insured is

OwnerTenantOther:

Type of Premises:

Owner's Name (If not insured):

Owner's Phone (A/C, No, Ext):

Address:

City:

State:

Zip Code:

Products:
Insured is

ManufacturerVendorOther:

Type of Product:

Manufacturer's Name (If not insured):

Manufacturer's Phone (A/C, No, Ext):

Address:

City:

State:

Zip Code:

Where can product be seen?

Other Liability Including Completed Operations (Explain)

INJURED/PROPERTY DAMAGED

Name (Injured/Owner):

Phone (A/C, No, Ext):

Address:

City:

State:

Zip Code:

Age:

Sex:

Occupation:

Employer:

Phone (A/C, No, Ext):

Address:

City:

State:

Zip Code:

Describe Injury:

Fatality

Where Taken:

What was injured doing?

Describe Property (Type, model, etc):

Estimate Amount:
$

Where can property be seen?

When can property be seen?

WITNESSES

Name:

Address:

City:

State:

Zip Code:

Res. Phone (A/C, No):

Bus. Phone (A/C, No, Ext):

Name:

Address:

City:

State:

Zip Code:

Res. Phone (A/C, No):

Bus. Phone (A/C, No, Ext):

Remarks:

Reported By

Reported To

	STATE INFORMATION APPLICABLE IN ARIZONA For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. APPLICABLE IN ARKANSAS, DELAWARE, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW JERSEY, NEW MEXICO, NEW YORK, PENNSYLVANIA, TENNESSEE, VIRGINIA AND WEST VIRGINIA Any person who knowingly and with intent to defraud any insurance company or another person, files a 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, subject to criminal prosecution and [NY: substantial] civil penalties. In DC, LA, ME, TN and VA, insurance benefits may also be denied. APPLICABLE IN CALIFORNIA For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN FLORIDA AND IDAHO Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.* * In Florida - Third Degree Felony APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN INDIANA A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. APPLICABLE IN MINNESOTA A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEVADA Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony. APPLICABLE IN NEW HAMPSHIRE Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Please click here if you have read and understood the applicable state information.