General Information

Policy Number

 Date of Loss

 Time of Loss

 Date Claim Reported

Insured / Policyholder Information

First Name

Last Name

Primary Contact Information

First Name of Primary Contact

Last Name of Primary Contact

Title / Relationship to Insured

Home / Primary Phone

 - -

Work Phone

 - -   Ext.

Cell Phone

 - -

Email Address

Alternate Contact Information

First Name of Alternate Contact

Last Name of Alternate Contact

Title / Relationship to Insured

Home / Primary Phone

 - -

Work Phone

 - -   Ext.

Cell Phone

 - -

Email Address

Information Regarding Loss

Location of Loss

Type of Claim        Please make a selection Identity Theft Other

Severity of Claim   Please make a selection Minor Moderate Severe

Brief Description of Claim:

Additional Information

First Name of Person Reporting Claim

Last Name of Person Reporting Claim

Title / Relationship to Insured

Enter your email address here
if you would like to receive an electronic confirmation that this claim has been successfully submitted.

Any person who knowingly files a statement of claim containing any false or misleading information
is subject to criminal and civil penalties.