Holder Insurance Agency

Notice of Liability Claim

Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from us. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST and call our office (800) 237-7795.

I, the policy holder, understand that filling out this form IS NOT binding. Changes ARE ONLY considered binding when I hear back from my agent indicating that they have received my request and will be processing it.

Today's Date:
From:
Company:
Phone:
Fax:
E-mail:
*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:

Additional Information
In the box below, please provide any additional information you feel may be necessary
for this Loss Notice form.

Where did you hear about our agency?