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: ________________________________