Claim Information Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Full name of individual(s) or firm involved in claim *

Full name of claimant *

Indicate whether

Claims/Suit
Incident

Date of alleged error *

Date of claim *

Description of claim: (Provide enough information to allow evaluation) *

Description of case and events *

If closed

Total loss paid including deductible

If pending

Claimant’s Settlement Demand

Defendant’s Offer for Settlement

Insurer’s Loss Reserve

Deductible

Is Claim in Suit

Yes
No

If yes, Amount asked in complaint

Name of Insurance Carrier *

Please describe procedures instituted to avoid like claims *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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