General Liability Claim Form

Fill out the incident report below.

An Intrepid claims service rep will review and contact you ASAP.

We’ll work with you and relevant parties to resolve the claim as quickly as possible

* indicates a required field

Reporter info (you)

Name of reporter *

First name

Last name

Reporter email *

Reporter phone *

Extension

Insured info

Insured business name

Policy number

Store number

Store address *

Address line 1

Address line 2

City

State

Zip

Insured contact first name *

Insured contact last name *

Insured contact phone *

Extension

Insured contact email

Claimant info

Claimant contact first name

Claimant contact last name

Claimant address

Address line 1

Address line 2

City

State

Zip

Claimant phone

Extension

Claimant email

Occurrence info

Date of occurrence *
Must be formatted MM/DD/YYYY

Time of accident
Please specify AM or PM

Location of occurrence

Description of occurrence *

Witness first name

Witness last name

Witness phone

Witness email

Do you have video footage? If so, please preserve the video.

Anything else?

Anything else you want to tell us?

Please leave this field empty.

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