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To process your claim, please complete the following information.

You will receive an email confirmation after submitting your claim.

* Company name:
* Policy #:
* Filing State:
* Preparer's name:
* Email:
* Phone #:
* Date of Incident:
* Date Incident Was Reported to Insured:
* Claimant's name:
* Claimant Address:
 
* City:
* State: * Zip:
* Address Where Incident Occurred:
 
* City:
* State: * Zip:
Again, if all of the required fields above are not filled in, we cannot process your claim and you will need to call 1-800-327-3636.
Account #:
Location Code:
Policy Exp. Date:
Company Address:
 
City:
State: Zip:

Incident Information

Time of Loss: AM PM
Full Description of What Happened,
Injury Type, Body Part,
Cause or Property Damage:
What Authorities Were Contacted?

Claimant Information

Phone:
Age:    Gender:    Male    Female
Social Security:
Claimant's Occupation:
Employer:
Address:
 
City:
State: Zip:

For Product Liability, Complete the Following

Type of Product that Allegedly
Caused the Damages:
Manufacturer's name:
Address:
 
City:
State: Zip:
Phone:
Name of Product that Allegedly
Caused the Damages
Where Product Can be Seen,
if it Has Been Discarded, Indicate So:

For Injury Complete the Following

name of Doctor or Hospital:
Address:
 
City:
State: Zip:
Phone:
What Injured Was Doing &
Description of Injury:

For Damaged Property, Please Complete the Following

Description of Damaged Property:
Where Can Damaged Property Be Seen
(i.e. claimant's possession, body shop)
Estimated Amount of Damage to
Claimant's Property:

Witnesses

Any Witnesses or Passengers? YES NO

Coverage Information

If available, complete only what applies to the loss

Liability (BI):
Liability (PD):
Prod/Compl Opr:
Fire/Legal Liab:
Occur Lim:
Gen Agg (K):
Prod Compl Oper Agg (K):
Ded Amt:
Ded Cov:
Ext Cov Ded:
Liab Ded:
Ded 1:
Ded 2:
% Co Ins:
Coins Lim
Forms and Endorsements:
Mortgagee 1:
Mortgagee 2:
Other Insurance-Specify:

Contact Person Regarding this Claim

Contact Person:
Address:
 
City:
State: Zip:
Phone:
Comments:

Need Help?

Contact a Service Representative.

(800) 327-3636
24 hours a day, 7 days a week.