Your Donation:$ 608
Click to Learn More ››
Pre Header Home Page Facebook Twitter LinkedIn Request A Quote Claims Make A Payment

General Liability Claim Form


Total Insurance Planning
13804 Hull Street Road, Suite 201
Midlothian, VA 23112
Phone: (804-) 595-1900
Fax: (804) 595-1901
Email: susan@totalinsuranceplanning.com
Agency Customer ID: 3346


DATE
Date of Loss and Time
Required
/ /
INSURED - EMPLOYER/MGR.
Store Name
Required
Primary Phone Number
Required
Business
Required
E-Mail Address
Required
CONTACT - INJURED PARTY
First Name
Required
Middle Name
Optional
Last Name
Required
Primary Phone Number
Required
When to Contact
Optional
LOCATION OF OCCURRENCE
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Country
Optional
Describe Location of Occurrence if Not at Specific Street Address
Optional
Were Police or Fire Department Contacted
Optional
Description of Occurrence
Optional
PROPERTY
Street Address
Optional
Address of Damage
Optional
City, State. ZIP Code
Optional
Primary E-mail Address
Optional
Primary Phone Number
Required
Damage
Optional
Describe Property (Type, Model, etc.)
Optional
WITNESSES
Name
Optional
Street Address
Optional
City, State. ZIP Code
Optional
LIABILITY
Injured Name
Optional
Street Address
Optional
City, State. ZIP Code
Optional
Primary Phone Number
Required
Primary E-mail Address
Optional
Age
Optional
Gender
Optional
Occupation
Optional
Describe Injury
Optional
What was injured Doing
Optional
WITNESSES
Name
Optional
Street Address
Optional
City, State. ZIP Code
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Learn More About

Useful Links

Preferred Partners

© 2013 Total Insurance Planning Midlothian VA, All Rights Reserved / 804.595.1900 · 13804 Hull Street Road Suite 201 · Midlothian, VA 23112