FNOL--Built from Template

Report a Claim
If you're an insurance agent or third-party, please complete this form to report a claim and we'll be in touch. If you're a policyholder with Coterie, go here to report a claim for faster service.
Carrier Name*
Policy Number*
If policy number is unknown, type in UNKNOWN
Date of Loss*

MonthDayYear
Date
If your loss date is outside of the policy period, please contact your insurance agent. If you need additional help, contact Coterie at 855-566-1011.
Policyholder Info
Policyholder Company Name
Policyholder Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Policyholder Contact Name

First NameLast Name
Policyholder Contact Phone Number
Please enter a valid phone number.
Policyholder Contact Email
example@example.com
Is the loss location different than the above?*

YesNo
Loss Location*

Street Address

Street Address Line 2

CityState

Zip Code
Choose a Loss Coverage Type*
Business Owner Policy (BOP)
What happened in the loss? (Please include as much info as you have available)*
What was damaged in the loss? (Please include as much info as you have available)
General Liability (GL)
What happened in the loss? (Please include as much info as you have available)*
What type of GL claim?*
Damage Claim (GL)
What was damaged in the loss? (Please include as much info as you have available)
Do you have the damaged property owners' information?

YesNo
Damaged Property Owner Name

First NameLast Name
Damaged Property Owner Phone Number
Please enter a valid phone number.
Damaged Property Owner Email
example@example.com
Damaged Property Owner Address

Street Address

Street Address Line 2

CityState

Zip Code
Injury Claim (GL)
Injury Loss Type
Part of Body Injured
Claimant Date of Birth

MonthDayYear
Date
Do you have the injured party's information?

YesNo
Injured Party's Name

First NameLast Name
Injured Party's Phone Number
Please enter a valid phone number.
Injured Party's Email
example@example.com
Injured Party's Address

Street Address

Street Address Line 2

CityState

Zip Code
Professional Liability (PL)
What happened in the loss? (Please include as much info as you have available)*
What was damaged in the loss? (Please include as much info as you have available)
Do you have the impacted party's information?

YesNo
Impacted Party's Name

First NameLast Name
Impacted Party's Phone Number
Please enter a valid phone number.
Impacted Party's Email
example@example.com
Impacted Party's Address

Street Address

Street Address Line 2

CityState

Zip Code
Witness Info
Was there a witness?

YesNo
Witness Name

First NameLast Name
Witness Phone Number
Please enter a valid phone number.
Witness Email
example@example.com
Witness Address

Street Address

Street Address Line 2

CityState

Zip Code
Acknowledgment
Your Name*

First NameLast Name
Agency Name*
Attorney Firm Name*
Your Relationship*
Your Phone Number*
Please enter a valid phone number.
Your E-mail*
example@example.com
Your Relationship to the Claim*
Please confirm the following*

I confirmed that all information in this form is accurate and true to the best of my knowledge. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Optional-Texting Consent

I hereby consent to receive text messages from Coterie at the phone number provided, understanding that standard messaging rates may apply. I may opt out by contacting my adjuster, sending STOP via the text message exchange, or calling 855-460-1420.As part of the Coterie Insurance digital payments option we can also send you a text message to speed up your payment processing. These texts would include invitation to submit your payment details, reminders, confirmations, and alert messages. If you do sign up for texting message and data rates may apply. You can opt out at any time by sending STOP to 63539 or you can call us for help at 855-460-1420.
Please verify that you are human*
Should be Empty:

Report a Claim

Policyholder Info

Business Owner Policy (BOP)

General Liability (GL)

Damage Claim (GL)

Injury Claim (GL)

Professional Liability (PL)

Witness Info

Acknowledgment