General Liability Property Damage Reporting Form

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GENERAL LIABILITY 
PROPERTY DAMAGE REPORTING FORM 
  
Insured Name:   _____________________________________________________________________________________  
DESCRIPTION OF PROPERTY DAMAGE 
Date of Loss: ___________________________  
 Location of Loss:   ___________________________________________________________________________________  
Description of Loss:   _________________________________________________________________________________  
 __________________________________________________________________________________________________  
Contact: _________________________________________________  Phone #: (______)  _________________________  
 
PROPERTY DAMAGE 
Describe Property Damage:  ___________________________________________________________________________  
 __________________________________________________________________________________________________  
 __________________________________________________________________________________________________  
Where can the damaged property be seen?  ______________________________________________________________  
 __________________________________________________________________________________________________  
Estimated Damage Value:   ____________________________________________________________________________  
 
COMMENTS 
 __________________________________________________________________________________________________  
 __________________________________________________________________________________________________  
 __________________________________________________________________________________________________  
 
 
 
Reported By: _________________________________________________ Phone #: (______)  ______________________  
 
Email: ______________________________________________________  Date:   ________________________________  

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