NORTH COUNTRY INSURANCE COMPANY

NORTH COUNTRY INSURANCE COMPANY GENERAL LIABILITY NOTICE/CLAIM

Date: Date of Occurrence: Time of Occurrence: Agency: Agency Phone #:	Date of Claim: Policy Number: Previously Reported: Yes No


Insured Info	Contact Info
Name: Address: City: State: Zip Residence Phone #: Business Phone #: Cell Phone #: Email Address:	Name: Residence Phone #: Business Phone #: Cell Phone #: Email Address: Where to Contact: When to Contact:
Occurrence
Authority Contacted:
Location of Occurence (Include City & State):
Description Of Occurrence:

Injured/Property Damaged
Name (injured/owner):
Address:	City:
State:	Zip:
Age:	Sex:
Occupation:	Employers Name & Address:
	Employers Phone #:

Describe Injury:
Where Taken?:
What was Injured Doing?:

Describe Property:
Estimate Amount:
Where can Property be seen?
When can property be seen?

Witness
Name:
Address:	City:
State:	Zip:
Residence Phone #:	Business Phone #:

Remarks:
Reported By:
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
The person completing this Loss Notice hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.