Liability Claim Report- For Customer Injury & Property Damage

Liability Claim Report

For Customer Injury & Property Damage
Store Type: McDonald's
Did this occur in Wisconsin or Illinois?*

WisconsinIllinois
Wisconsin*
Illinois*
Owner's Name: Guy Bucciferro III
Company Name: Iron Arch Management LLC
Policy # 48-XU0440-01
Are you submitting for customer injury or property damage?*

Customer InjuryProperty Damage
What is your General Manager's name?*
Restaurant Phone Number

Area CodePhone Number
Who was the incident reported to?*
First and Last Name
Date Restaurant Notified

MonthDayYear
Was Manager on duty notified immediately?

YesNo
Time Manager Notified

Hour Minutes

AM/PM Option
Your Name*

First NameLast Name
What is your title? *
Date of Incident*

MonthDayYear
Time of Incident*

Hour Minutes

AM/PM Option

Liability Claim Report