SUBMIT A CLAIM Submit a Claim Form design for handling claim submissions. "*" indicates required fields INSURED NAMEInsured Name* First Last ADDRESSAddress* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Work PhoneEmail Address AGENT NAMEAgent Name First Last Policy Number Date of Loss* MM slash DD slash YYYY Time of Loss* Hours : Minutes AM PM AM/PM LOCATION OF LOSSLocation of Loss* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Reported to Police or Fire Department?*YesNoType of Loss*FireLightningWindHailWaterTheftSmokeVandalismInjuryOtherDescribe the Loss*Mortgage on Property Where Loss Occurred*YesNoOther Insurance Covering the Property*YesNoREPORTED BYReported By* First Last CONTACT NAMEContact Name* First Last Your Daytime Phone*Relationship to Insured Anti-Fraud Notice Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submist an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Disclaimer This claim will be reviewed and contact will be made as soon as possible on the next regular business day following receipt of this notice. We may not receive this claim promptly if the report is being completed after hours or on weekends or holidays. This reporting capability is solely for the convenience of filing a claim after hours or when it is not feasible to contact your agent during normal business hours.Authorized Request* By checking this box, I hereby certify that I have the authority to make this request by being insured or a representative of the insured. Did You Know? If you decide to file a claim, make sure to keep track of all expenses that are associated with the claim, as these could be eligible for reimbursement.
