Contact Us  |  April 25, 2017

Liability Claim (other than auto)

To expedite the processing of your claim, please complete this notice with as much information as you have available.
Contact Information
Name: *
Daytime Phone Number: *
Fax Number:
Email:
Best Time to Call: *
Insured Information (for Business Customers only)
Company Name:
Address:
City:
State:
Zip Code:
Loss Information
Date of Loss: *
Loss Location: *
Brief Description of Loss: *
Police Contacted? * Yes  No
If so, Which Police Department?
Any Other Authority Contacted? Yes  No
If so, Which Authority?
Injury Information
Injured Party Name: *
Injured Party Address:
City:
State:
Zip Code:
Injured Party Daytime Phone Number:
Brief Description of Injury: Include a description of what the injured was doing?
Was Injury Fatal? Yes  No
Witness Information
Please enter name, address, and daytime phone numbers for each witness.
Additional Comments
Please enter any additional comments you feel we need about this claim.
* = Required Field
You will be contacted by a representative of Marsh & McLennan Agency LLC (formerly Kinker-Eveleigh Insurance Agency) within 24 hours of our receipt of this form. If you do not hear from us, please call our office at (513) 248-4888. Please note that submission of this form does not constitute notice of a claim to either Marsh & McLennan Agency or your respective insurance company until confirmed by Marsh & McLennan Agency or your insurance company.