SRST General Liability Loss Form

"*" indicates required fields

Insured: STANDING ROCK SIOUX TRIBE

Department*

Date of Loss

Time of Loss

:

Claimant

Name*

Phone

Address

Street Address City ZIP / Postal Code

Email

Location of Injury or property damage

Police or Fire Dept Contacted

Describe Injury

Describe Property

Witness

Name

Phone

Address

Street Address City ZIP / Postal Code

Description of Occurrence

Insured Contact Info

Claim Contact

Contact Email

Authorized By

Contact Phone