McMartin, Wasek & Associates, Inc. - Adjustment Services for the Millennium

10370 Citation Drive, Suite 100

Brighton, MI 48116

Phone:  866-937-7009

Fax:     (989) 229-8039

P.O. Box 888364

Grand Rapids, MI 49588

Phone:  866-937-7008

Fax:     (989) 893-0208

Please complete the following form. When finished, print this page for your records.
(Required fields are marked with a *.)
General Liability Loss Notice
Date: *
AGENT: * Address: *
Phone: * City / State: *
Fax: * Zip: *
COMPANY: * Address: *
Adjuster: * City / State: *
Company Phone: * Zip: *
Company Fax: *
Policy Number: * Policy Eff. Date: *
Claim Number: * Policy Exp. Date: *
Date & Time of Loss: *
Previously Reported: * Yes No

 

Insured
First Name: * Insured's Residence Phone:
Last Name: * Insured's Business Phone:
Address: * Person to Contact:
Address (second line): Where to Contact:
City: * When to Contact:
State:* Contact's Residence Phone: *
Zip: * Contact's Business Phone: *
Fax:

 

Loss
Location of Accident:


Description of Accident:


Authority Contacted & Report Number:

 

Policy Information
Coverage Part or Forms (Insert Form Numbers and Edition Dates):
Limits Premises /
Operations		 Med. Pay Products /
Completed
Operations		 Contractual Other Deductible
BI $ $ $ $ $
PD $ $ $ $ $
CSL $ $ $ $ $
Umbrella / Excess Policy in Force:
Umbrella Excess		 Carrier:
 Limits:



Type of Liability
Insured is:
Owner Tenant Other		 Type of Premise:
Owner (If Not Insured)
Name: Phone:
Address: Fax:
City / State:
Zip:
Product Insured:
Manufacturer Vendor Other		 Type of Product:

Where can the Product be Seen?


Other Liability Including Operations (Explain):

 

Injured / Damaged Property
Injured / Owner
Name: Phone:
Address: Occupation:
City / State: Age:
Zip: Sex: Male Female
Employer
Name: Phone:
Address: Fax:
City / State:
Zip:
Injury Description: Fatality


What Was The Injurer Doing:


Where Taken: 
Describe Property:
Estimate Amount:
Where and When can the Property be Seen:

 

Witnesses
Name: Business Phone:
Address: Residence Phone:
City / State:
Zip:

Remarks:
Reported By: Reported To: