Texas All Risk Group of Companies, Texas All Risk General Agency, All Risk General Agency, Inc., TARGA Premium Finance, Select General Agency, L.L.C.

General Liability Loss Notice

Please use the form below to notify us of any product/equipment loss or damage covered through your general liability policy through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Disclaimer

I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Insured / Your Company Name:
Policy #:
Contact Name:
Address:
Phone #:	Office     Mobile
Email:

Time and Description of Loss
Time & Date of Loss	Time a.m. p.m.     Date
Incident Location:
Incident Description:

Authority Notification
Were the Police or Fire Dept. Called?	Yes     No
If Yes, which Authority?
Report #:
Authority Phone #:

Product or Equipment Involved
Product Name:
Purchased from:
Phone: (Purchased From)
Manufacturer Name:
Phone: (Manufacturer)

Customer or Person Involved (not an employee)
Name:
Address:
Phone:	(Daytime)     (Mobile or other)
Type of injury:
Where taken:
Property Damaged:
Property damage estimate:

If injured person was working for another employer at the time of the incident, add info below
Employer Name:
Employer Address:
Employer Contact:
Employer Phone:

Witness Information
Witness Name:
Phone: (Witness)

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

Please click on the "Submit Form" button to send your service request.
One of our representatives will respond to your submission as soon as possible.

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