General Liability Loss

General Instructions

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

  • You can open/close any section of this form at any time by clicking a gray section header below.
  • If the mandatory information is unknown at the time of your web submission, enter "unavailable" in any field requiring text.
    Enter only numerals(1,2,3, etc.) in all fields that require a number value.
  • The final report will depend on the accuracy and completeness of the information you are able to provide.
  • No information will be transmitted until you click the "submit" button at the bottom of the form.
  • The Accident Description field will have a 200-character limitation. Additional information can be entered in the final remarks area of the submission. Additional Remarks will have a 200-character limitation.

Emergencies

If your loss is severe, RISCOM recommends that you phone in your loss to 318-698-6600 or after hours to 318-286-8705 to insure that it receives the immediate attention it needs.

General Information >>
1. Date & Time of Accident
Date of Accident: (MM/DD/YYYY)      Time of Accident:  
2. Person Reporting
First Name:      Last Name:
Telephone Number: - -      Secure Fax Number: - -
Relationship to Incident:
I am a (choose one):
3. Insured Information
'
Insured Name (Company Name):
I use a DBA (Doing Business As) Name:
Address:
City:     State:      Zip: -   
Telephone Number: - -      Contact Name:
Policy Number:       Effective Date: (MM/DD/YYYY)
Agent Name:
Location Information >>
4. Work Location Information (location of job)
Location Name:
Address:
City:     State:      Zip: -   
Telephone Number: - -      Secure Fax Number: - -
Date Insured Was Notified: (MM/DD/YYYY)      Time Insured Was Notified:  
5. Loss Location Information (where accident occurred)
Location Name:
Address:
City:     State:      Zip: -   
Location on premises Where Accident Occured:
Injury Information >>
6. Incident Description




Which Insured Employees were Present and Saw the Accident or were involved in the accident:
Was an Accident report prepared:
Were the Authorities called :
Who Responded:
Report Number:
What Third Parties were at the Site of the Accident:
7. Injury Information
'
Injured: Fatality Involved: Total Number of Injuries:
Injured 1
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:     Date of Birth: (MM/DD/YYYY)      Gender:      Social Security Number:
What Was the Person Doing When Injured:
Injury Description:
Was Treatment Provided:   Was Injured Transported by Ambulance:
If Yes, Where Was Treatment Provided:
Facility Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Fatality:     
Additional Injury 1 >>
8. Additional Injured 1 - Information
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:     Date of Birth: (MM/DD/YYYY)      Gender:      Social Security Number:
Location on Premises Where Accident Occurred:
Injury Description:
Was Treatment Provided:      Was Injured Transported by Ambulance:
If Yes, Where Was Treatment Provided:
Facility Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Fatality:
Additional Injury 2 >>
9. Additional Injured 2 - Information
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:     Date of Birth: (MM/DD/YYYY)      Gender:      Social Security Number:
Location on Premises Where Accident Occurred:
10. Additional Injured 2 - Incident Description
What Was the Person Doing When Injured:
Injury Description:
Was Treatment Provided:   Was Injured Transported by Ambulance:
If Yes, Where Was Treatment Provided:
Facility Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Fatality:
Property Damage >>
11. Property Damage Information
Was There Any Property Damage:
First Name:     Last Name:
Company:     
Address:
City:     State:      Zip: -
Telephone Number: - -   Contact Name:     
Contact E-mail:     
Describe Property:
Witness Information >>
12. Witness Information
Were There Any Witnesses to the Incident:
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Type:   If other explain:
Closing Information >>
13. Contact Information
First Name:      Last Name:
Telephone Number: - -     Cell Phone Number: - -
Your Email Address:
If you wish to receive a claim acknowledgement, please enter a fax number to send to: - -
14. Additional Remarks
Enter any additional remarks you would like to make in the space below: