Incident Report Form | Hospitality Insurance Group

Policyholder and Agency Information

policyholder First Name

policyholder Last Name

Policyholder address

City/State

Zip Code

Policyholder email

Policyholder phone number

Agency Name

Policy Number

Incident/Loss Information

date of Incident

Time of Loss

Location address

City/State

Zip Code

Please select Type of Incident:

Liquor Liability

Assault and Battery

General Liability

Commercial Property

Description of Loss

Injury or damage sustained

Signed By

I declare under penalty of perjury under the laws of the United States of America that the information in this Notification of Claim is true and correct.

Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of a claim or notification of a claim containing false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

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