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GENERAL LIABILITY FORM
Flat fee to include up to 2 statements and scene photos in matters where we can confirm that no claim is being pursued by the Claimant and non-injury statement is obtained. Report included
Investigations and report up to 3 recorded statements in Blind Claims or First Notice Lawsuits

(General liability claims assignment sheet sent to Everglades Claims Investigations)

*Company Name

(Liability Claims Department)

*Company Address

*Company Phone (include area code):
( )

*Company Claim Number

*Date of Loss (mm/dd/yyyy)
/ /

*Insured Employer

*Store Location Number

*Store Address

*Store Phone (include area code):
( )

*Claimant

*Claimant Address

*Claimant Phone (include area code):
( )

*Examiner Name

*Examiner Ext.

*Examiner E-mail

General Liability Investigation to include statements of:

Statement 1

Statement 2

Statement 3

ATTACHMENTS: If you wish to send incident or claims reports, please attach them to a separate e-mail addressed to ABerg65277@aol.com. Please reference the Company Claim Number listed above in the email.

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