Liability Claim Report

Liability Claim Reporttbelford2018-02-13T10:51:54-05:00

Liability Claim Report

If you are reporting a Liability Claim, please print and review this information first:

Liability Loss Tips

Company Reporting: To report your claim directly to your Insurance Company, use the information provided here:

Company Claims Reporting

IRMS Reporting: To report a Liability Claim to IRMS, please complete this form and click “Submit”.

If you need assistance, please contact your Client Service Manager.

Contact Information
Client Name
Contact Name
First Last
Name of Business
Phone Number
Email Address
General Information
Date of Incident
MM slash DD slash YYYY
Location of Incident
Description of Incident
Other Party Information
Other Party's Full Name\Business Name
Name
Other Party's Phone Number
Additional Comments
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