Liability Claim Questionnaire - CAL Insurance & Associates

Liability Claim Questionnaire

	First call CAL, then complete the following form.
Name of Business:
Your Name:	Phone #:
e-mail:
Reported to Police/Fire?:	Yes No	Case #:
Date of Loss:		Time of Loss:
Location of Loss:

Description of Loss:
Estimated Value of Loss:	$
Was Anyone Hurt?	Yes No
	Name:
	Address:
	Phone #:
Does the Cause of Loss Still Exist?		Yes No
Is the Loss Preveinting Ongoing Operations:		Yes No
Corrective Action Taken:
(If Already Fixed or Repaired, Keep All Damaged Property For Inspection by Adjuster)

Safety Precautions Taken to Prevent Injury to Others :

Witness Information:	Name:
	Phone #:
	Address:

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