Name: Preferred Insurance
Address: 4035 Ridge Top Road, Fairfax, VA, 22030, US
Telephone: (703) 359-5910

Insured
Date*
MM slash DD slash YYYY
Business Name*
Contact Name*
Daytime Phone Number*
Email*
Loss Information
Date of Loss*
MM slash DD slash YYYY
Time of Loss (e.g., 12:30 PM)
Location Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Police Department
Report Number
Accident Description*
Property Damaged
Owner
Address of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day/Evening Phone
Approximate Value
Description of Loss*
Additional Information
Injured
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Injured Body Part
Transported to Hospital?
Fatality?
Nature of Injury
Phone
Additional Information
Comments or Witness Information
Attachments
Max. file size: 59 MB.
Name
This field is for validation purposes and should be left unchanged.

General Liability Loss Notice