                          GENERAL LIABILITY NOTICE               DATE ________

PRODUCER:  PHONE ___ ___ ____ EXT ____   MISCELLANEOUS INFORMATION: __________
 _____________________________________   _____________________________________
 _____________________________________   COMPANY: ____________________________
 _____________________________________   POLICY NO: __________________________
 _____________________________________   POLICY EFF DATE: ____________________
 _____________________________________   POLICY EXP DATE: ____________________
CODE: __________   SUBCODE: __________   DATE/TIME OF LOSS: __________________
INSURED                                  PREVIOUSLY REPORTED:  ___ YES  ___ NO
NAME AND ADDRESS:                        RES PHONE ___________________________
 _____________________________________   BUS PHONE ___________________________
 _____________________________________   CONTACT: ____________________________
 _____________________________________   WHEN: ____________ WHERE: ___________
 _____________________________________   CONTACT RES PHONE: __________________
OCCURANCE                                CONTACT BUS PHONE: __________________
LOCATION OF OCCURANCE ________________   POLICE OR FIRE DEPT TO WHICH REPORTED
 _____________________________________   _____________________________________
 _____________________________________   _____________________________________
DESCRIPTION OF OCCURANCE _____________________________________________________
 _____________________________________________________________________________
POLICY INFORMATION
COVERAGE PART OR FORMS _______________________________________________________
GEN AGG _______ PROD/OPS ________ PER INJ ________ OCC ________ FIRE DAM _____
MED EXP _______ DED AMT  ________ TYPE _________________ PER CLAIM _ PER OCC _
UMBRELLA/EXCESS POLICY IN FORCE?     UMBRELLA/EXCESS CARRIER    UMB/XS LIMITS
 _ UMBRELLA  _ EXCESS                _______________________    ______________
TYPE OF LIABILITY
PREMISES: INSURED IS ___ OWNER  ___ TENENT   ___ OTHER   TYPE OF PREMISES:
OWNERS NAME & ADD ______________________________________ _____________________
PRODUCTS: INSURED IS ___ MANUF  ___ VENDOR   ___ OTHER   TYPE OF PRODUCT:
MANUFS NAME & ADD ______________________________________ _____________________
WHERE CAN PRODUCT BE SEEN? ___________________________________________________
OTHER LIABILITY INCL COMP OPS ________________________________________________
INSURED/PROPERTY DAMAGED
NAME & ADDRESS    ____________________________________________ PHONE _________
AGE __  SEX _  OCCUPATION ____________________________________________________
EMPLOYER NAME & ADD __________________________________________ PHONE _________
DESCRIBE INJURY _____________________________ WHERE TAKEN ____________________
WHAT WAS INJURED DOING? ______________________________________________________
DESCRIBE PROPERTY ___________________________ ESTIMATE AMOUNT ________________
WHERE CAN PROPERTY BE SEEN? _________________________________ WHEN? __________
WITNESSES
 NAME & ADDRESS                        BUSINESS PHONE      RESIDENCE PHONE
 ____________________________________  __________________  ___________________
 ____________________________________  __________________  ___________________
REMARKS ______________________________________________________________________
REPORTED BY __________________________   REPORTED TO _________________________
PRODUCER'S SIGNATURE ___________________________________________ DATE ________
