Public Liability Claim

   Type of Claim:  
 

Name:

  
 

Address:

  
  Policy Number:  
 

Policy Effective Date:

  
  E-mail:  
  Agency:  
 

Agent:

  
       Residence Phone:  
 

Mobile Phone:

  
 

Business Phone:

  
       
 

Public Liability:

  
       
 

Description of the event:

 		  
       
 

Injured Parties:  Include name, age and address of each party.  Indicate the nature of the injuries,where they received  medical attention. If there were any hospitalizations, name hospital/hospitals.

  
  Injured Parties:  

Real Legacy Assurance Company, Inc.

P.O.Box 71467
San Juan, P.R.
00936-8567

Metro Office Park
Calle 1 Lote 4
Guaynabo, P.R. 00968

Subsidiary of

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