You must have JavaScript enabled to use this form. Insured Name First Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Primary Phone Work Phone Email Address Agent Name First Last Policy Number Date/Time of Loss Date/Time of Loss: Date Date/Time of Loss: Time Location of Loss Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Reported to Police or Fire Department? - Select -YesNo Type of Loss - Select -FireLightningWindHaulWaterTheftSmokeVandalismInuryOther Describe the Loss Mortgagee on Property Where Loss Occurred - Select -YesNo Other Insurance Covering the Property - Select -YesNo Remarks Reported By First Last Contact 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, submits 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 the insured or a representative of the insured. Submit 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.
