General Liability Claim Form

If your house/alumni corporation and undergraduate chapter is part of a national fraternity insurance program, you are still required to provide the Executive Director/Executive Vice President with notification.

Date of Incident
MM slash DD slash YYYY
National Fraternity Affiliation*
Chapter Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Email*
Chapter President Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Chapter Advisor Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
House Corporation President Name
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Injured Party's Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Nature of Injury
Taken to the hospital?
- Yes
- No
Hospital
Admitted
Is the injured party and associate or member?
- Yes
- No
Description of What Happened
Witness 1 Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Witness 2 Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Witness 3 Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of person completing report
First Last
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General Liability Claim Form

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