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Back to Report a Claim

General Liability Claim Form

Before filling out the form below, read the following instructions.

Instructions To Insured

  1. Please note that the submission of this form to us does not of itself bind, initiate or alter any of the conditions of your insurance program. Confirmation of any material changes to your policies can only/will only be made through contact with a Bolton & Company representative.
  2. Provide all documents you have regarding this incident including:
    • Copy of lawsuit, if filed
    • Documents provided by claimant including medical bills.
    • Internal documents including any investigation of the incident, repair and maintenance records, etc.
  3. Provide names and address of any witnesses to the incident or employees who may be able to provide details on the product or location involved in the incident.
  4. If a product is involved & you have the product, save this for inspection by the claims adjuster or an expert named by the insurance company.
  5. The claim adjuster will deal directly with the claimant or his/her attorney; you should not deal with them yourself.
  6. Expect to be contacted by the claims adjuster within 48 hours.
  7. If there is any reason that you need to be contacted immediately, please let us know.


Fields marked with * are required fields.

Contact Information
Please provide us with your contact information.
* First Name:
* Last Name:
* Street Address:
* City:
* State/Province:
* Zip/Postal Code:
Country:
* Day Phone:
Evening Phone:
Fax:
* E-mail:
 
Information about the Occurrence
 
Date of Occurrence:
Location of Occurrence:
Description of Occurrence:
Authority Contacted:
 
Property Damage
Please provide us with information about any property damage.
Was there property damage?
Yes No

If yes, the following information is required.
Property Owner Name:
Property Owner Day Phone:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Description Of Damage:
 
Injuries
Please provide us with information about any injuries.
Was anyone injured?
Yes No

If yes, the following information is required.
Injured 's Name:
Description of Injury:

Fatality?
Injured 's Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Day Phone:
 
Additional Information
Please provide us any additional comments you might have.
Additional Comments:

 
Submit Claim

Please click on the "Submit Claim" button below to send us your claim.
 
 
   
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