Claims Form

Date of Loss:

Date Reported:

Policy Number:

Insured Name:

Insured Address:

Contact Person:

Contact phone:

Cause of Loss:
FireLightningTheftWater/Sewer BackupCollapse (dwelling, private structure and/or PH48)Collision/OverturnOther

If cause of loss is other, please explain:

Location of Loss:

Details of Loss:

Agent submitting claim:

Agent submitting claim Email: