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General Liability/Property Claim Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Policy Information
Date & Time of Loss
Required
Carrier
Optional
Policy Number
Optional
Insured Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Contact Information
Contact Insured
Optional
Name (First, Last)
Optional
Phone Number
Optional
Mailing Address
Optional
Email Address
Optional
When to Contact
Optional
Incident Overview
Street Address
Optional
City, State. ZIP Code
Optional
Police or Fire Department contacted
Optional
Report Number
Optional
Describe the location of incident if not at specific street address
Optional
Describe the incident.
Required
Type of Liability
Premises
Insured is
Optional

Owner's Name & Address (If not insured)
Optional
Type of premises
Optional
Phone Number
Optional
Email Address
Optional
Products
Insured is
Optional

Manufacturer's Name & Address (If not insured)
Optional
Type of product
Optional
Phone Number
Optional
Email Address
Optional
Injured / Property Damaged
Name & Address (Injured/Owner)
Optional
Phone Number
Optional
Email Address
Optional
Age
Optional
Gender
Required
Occupation
Optional
Where Taken
Optional
Describe Property
Optional
Estimate Amount
Optional
Where can property be seen?
Optional
Employer's Name & Address
Optional
Phone Number
Optional
Describe Injury
Optional
What was Injured doing?
Optional
Witnesses
Name & Address
Optional
Phone Number
Optional
Email Address
Optional
Name & Address
Optional
Phone Number
Optional
Email Address
Optional
Name & Address
Optional
Phone Number
Optional
Email Address
Optional
Remarks
Optional
Submission Validation
Required
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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.
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Please note that we cannot bind insurance via email, fax, or phone. Any quotes given are subject to underwriting guidelines by the respective insurance carriers. Any reference of coverage used are not intended to express legal opinion as to the nature of coverage, but rather just a brief generalization of coverages. Please read your policy for specific details of coverages.

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ECI Agency, Inc. | 325 Piedmont Rd N | P.O. BOX 600 | Piedmont, OK 73078 | Phone: (405) 373-2977 M-F 8am-5pm