Preliminary Claim Information

It happens! And when it does, we’re here for you.

Please give us some background information about your loss, and we will contact you as soon as possible.

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Name of Insured *

First

Last

Name of policyholder.

Address *

Phone Number *

Email *

Preferred Method of Contact *

• Call
• Text
• Email

Type of Claim *AutomobilePersonal PropertyBusiness PropertyLiabilityPersonal InjuryOther

Location of Incident *

Is there a police report? *YesNo

Responding Police Department

Incident Report Number

Was anyone injured? *YesNo

Briefly describe any injuries:

Cause of Loss *

EX: Impact, Weather, Theft, Vandalism, Hit While Parked, etc.

Name of Driver 1

First

Last

If different than named insured.

Vehicle Year, Make, and Model

Vehicle Identification Number (VIN)

Briefly describe any vehicle damage:

If none, type NONE.

Loss of Item(s)

Name of Claimant

First

Last

Please provide claimant name if different than named insured or driver listed above.

Address of Claimant

Phone Number of Claimant

Vehicle Make and Model

Include additional property damage, drivers involved, or other notes:

Submit

It is the insureds responsibility as per the insurance contract to (1) notify your agent or company promptly about where, when, and how the loss occurRed; (2) prevent property from further damage; (3) assist and cooperate with agent and company.