Customer Accident

All information indicated by an asterisk * is required in order to submit a claim.
If you do not know the required information, please enter ? in the form field.

Business Contact Information
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To receive confirmation that your claim has been reported, please enter your e-mail address.
 
Injured Customer Information
[to be obtained by adjustor]
[to be obtained by adjustor]
,
Specify exact location, eg. aisle, department, inside, outside, etc. Include part of the body affected or nature of property damage
Landlord Information (applicable if the property is leased)
Title
,
Fax Number:
Witness Information (Name, Address, Phone, including employees)
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Name
,
,
 

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