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Claim Intake Form

This is an internal claim form for Liberty employees only. Clients and external individuals should not fill out this form.

Workers' Comp Claim?

To submit a WC claim: Please contact the Workers’ Comp Practice Group: wcpracticegroup@libertycompany.com

Client Service - Claim Submission v2

Liberty Point of Contact Information

Must be an @libertycompany.com email address

Policy Holder Information

Does the policy holder have a separate mailing address?
Agriculture account?

General Claim Information

Claim Type
Has this claim already been reported?
What occurred?
Is Claim Litigated?
Is this account related to other accounts?
Is this a notice only incident?

Property Claim Information

What did the loss involve?
Is any interior section of the building now exposed to the outdoors and unprotected?
Can the building be occupied?
$
$

Insured Vehicle Information

Does the Insured own the vehicle?
What was damaged, if anything?

Insured Vehicle Damage Information

Maximum file size: 268.44MB

Is there a WRITTEN estimate or repair/replacement bill for the damage?
$
Is the vehicle drivable?
Did the air bag deploy?
Is the Insured represented by an attorney?

Vehicle Owner Information

Vehicle Owner's address
Vehicle Owner's address
City
State/Province
Zip/Postal
Country

Injured Person Information

What vehicle was this person in?
Relationship to the Insured
Address
Address
City
State/Province
Zip/Postal
Country
plus1 Add information for another Injured Person minus1 Remove this Injured Person

Damaged Vehicle Information

Address
Address
City
State/Province
Zip/Postal
Country
$
Did airbag deploy?
plus1 Add another damaged vehicle minus1 Remove this damaged vehicle

Damaged Property Information

Address
Address
City
State/Province
Zip/Postal
Country
$
plus1 Add another damaged property minus1 Remove this damaged property

Maximum file size: 268.44MB

Additional Information

Routing Information