Claims Submission

Disclaimer

I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.    I have read and agree with the above disclaimer.     (Box must be checked before request can be sent)

 

 

Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Name Insured:
Address:
Phone #:	Work     Home
Email:
Policy Number:

 

 

Time and Description of Loss
Time & Date of Loss	Time a.m. p.m.     Date
Location of Property:
Description of Loss:

 

 

Authority Notification
Were the Police or Fire Dept. Called?	Yes     No
If Yes, which Authority?

 

 

Property Status
Is the Property habitable?	Yes     No
If No, where are you staying:	(Address and Telephone)

 

 

Report Information
Reported by:
Title (if any):
Date:

 

 

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

 

Please click on the "Submit Form" button to send your Loss Notice.
One of our representatives will respond to your submission as soon as possible.