ACORD ™ 

GENERAL LIABILITY NOTICE OF OCCURRENCE/CLAIM
DATE  
PRODUCER
PHONE: (A/C, No, EXT)
CODE:
SUBCODE:
AGENCY CUSTOMER ID:

NOTICE OF OCCURRENCE DATE OF OCCURRENCE AND TIME
 DATE OF CLAIM
 PREVIOUSLY
REPORTED
NOTICE OF CLAIM
AM PM		 YES NO
EFFECTIVE DATE
 EXPIRATION DATE
 POLICY TYPE
OCCURRENCE
CLAIMS MADE		 RETROACTIVE DATE
COMPANY

NAIC CODE: 		MISCELLANEOUS INFO (Site & location code)
POLICY NUMBER

 REFERENCE NUMBER
INSURED CONTACT      CONTACT INSURED
NAME AND ADDRESS OF INSURED


 SOC SEC # OR FEIN:
 NAME AND ADDRESS OF INSURED
RESIDENCE PHONE (A/C, No)
 BUSINESS PHONE (A/C, No, Ext)
RESIDENCE PHONE (A/C, No)
 BUSINESS PHONE (A/C, No, Ext)
WHERE TO CONTACT
 WHEN TO CONTACT
OCCURRENCE
 
POLICY INFORMATION
 
TYPE OF LIABILITY
PREMISES: INSURED IS OWNER TENANT OTHER: TYPE OF PREMISES
OWNER'S NAME & ADDRESS (If not insured)
OWNERS PHONE (A/C, No, Ext):
PRODUCTS: INSURED IS MANUFACTURER VENDOR OTHER: TYPE OF PRODUCT
MANUFACTURER'S NAME & ADDRESS (If not insured)
MANUFACT PHONE (A/C, No, Ext):
WHERE CAN PRODUCT BE SEEN?
OTHER LIABILITY INCLUDING COMPLETED OPERATIONS (Explain)
INJURED/PROPERTY DAMAGED
NAME & ADDRESS (Injured/Owner)


 PHONE (A/C, No, Ext)
AGE
 SEX
 OCCUPATION
 EMPLOYER'S NAME & ADDRESS


 PHONE (A/C, No, Ext)
DESCRIBE INJURY WHERE TAKEN WHAT WAS INJURED DOING?
FATALITY
DESCRIBE PROPERTY (Type, model, etc) ESTIMATE AMOUNT WHERE CAN PROPERTY BE SEEN? WHEN CAN PROPERTY BE SEEN?
WITNESSES OR PASSENGERS
NAME & ADDRESS BUSINESS PHONE (A/C, No, Ext) RESIDENCE PHONE (A/C, No)


REMARKS (Include adjuster assigned)
REPORTED BY
 REPORTED TO
 SIGNATURE OF INSURED
 SIGNATURE OF PRODUCER
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, District of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, New York, Pennsylvania, Tennessee and 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
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company 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 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
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.
ACORD 3 (2002/01)