BTV Claims - Hickok & Boardman Insurance Group

City of Burlington Claims Reporting: General Liability

Your Name*
First Last
Phone
Your email address*
Enter Email Confirm Email
Claim Contact Person
Name
First Last
Contact Phone
Dept Supervisor
First Last
Contact Email Address
City Department
Time & Place
Date of Loss or Accident
MM slash DD slash YYYY
Time of Loss or Accident

: Hours

Minutes

AM/PM
Location of Loss or Accident
Street Address Address Line 2 City State ZIP Code
Officials Called to Scene
- Fire
- Ambulance
- Police
From which locale?
Injured Party - Property Damage
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claimant Age
Extent of Damage
Location of Property
Street Address Address Line 2 City State ZIP Code
Injured Party - Bodily Injury
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Claimant Age
Describe Extent of Injury:
Summary
Description of Claim (General Liability). If involving Contractor's Equipment, please include Make, Model & Year of Vehicle.
Witnesses & Injuries
Were there any witnesses?
- Yes
- No
List the Names, Address & Telephone numbers of any witnesses:
Name
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