Liability Loss Notice All fields are required. Policy Number     Person Insured Name     Address     City     State     Phone Number  xxx-xxx-xxxx   Person to Contact     Lost Liability Date of Loss  mm/dd/yyyy     Location of Loss (premises location, city, state)   Description of Loss   Bodily Injury YesNo Injury Description   Property Damage YesNo Damage Description   Persons Involved Name of Claimant, Address, Phone   When to Contact     Witnesses (name, address, phone)     Remarks   Person making report (name and phone)

3905 South 148th Street, Suite 100                                              Omaha, NE 68144                                                                                            800-642-8572

© 2010 Cooperative Mutual Insurance Company. All Rights Reserved.
Created in partnership with VistaComm®