Submit a Claim | Pike Mutual Insurance Company

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Insured Name

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Primary Phone

Work Phone

Email Address

Agent Name

First

Last

Policy Number

Date/Time of Loss

Location of Loss

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reported to Police or Fire Department?

Type of Loss

Describe the Loss

Mortgagee on Property Where Loss Occurred

Other Insurance Covering the Property

Remarks

Reported By

First

Last

Contact Name

First

Last

Your Daytime Phone

Relationship to Insured

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 the insured or a representative of the insured.