Form - Liability Claim - Client Documents Portal

Claim form

York Pooling - your claim must be submitted within 6 months of the incident (Government code 911.2)

Today's Date*
MM slash DD slash YYYY
Name
First Last
Entity Name:
Group or JPA Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Gender
- Male
- Female
Date of incident/accident:
MM slash DD slash YYYY
Date injuries, damages, or loss was discovered:
MM slash DD slash YYYY
Location of incident or accident (address if applicable):
Describe specific injuries, damages, or loss incurred:
Describe causation of loss, damages, or injury:
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Accepted file types: doc, jpg, png, gif, pdf, Max. file size: 50 MB.