Tanner, Ballew and Malloof, Inc.

Report a General Liability Claim

* Required fields

Please provide as many details as possible in order to avoid delay in reporting this claim to your insurance carrier. All fields indicated with an asterik (*) must be completed.
*Submitted By: First Name:    Last Name:
*Company:
Location Code:
Email Address:
*Telephone Number:
*Date of Incident: Time of Incident: AM PM
*Location of Incident:
*If Restaurant, please indicate: Store #: Drive-thru In Store Carry-out
*Description of Incident:
Manager on Duty: Telephone Number:
*Injured Party or Owner of Property Name, Address and Telephone:
*If a minor, name of Guardian (address & telephone, if different:
Age: Sex: FemaleMale Occupation:
*Describe Injury or Damage to Property:
If alleged foreign body, please hold evidence. Describe product and foreign object:
If alleged illness, please hold evidence. Describe product and symptoms:
If alleged slip and fall, please describe shoes worn, condition of floor and any obstructions:
Medical Treatment Provided? Yes No Provider:
Transported by Ambulance? Yes No If yes, where taken?
WITNESSES
Witness 1 (including address and telephone number):
Witness 2 (including address and telephone number):
ADDITIONAL INFORMATION
To submit your claim, please click the "Submit" button.
A confirmation will be sent to you by email.