New Claim Form | GuideOne Insurance

New Claim Submission Form
Today's Date*

MonthDayYear
DateHourMinutesAM/PM Option
Loss Date*

MonthDayYear
Date
Type of Claim*
Property/Building Damage - Loss to a structure such as fire/wind/hail. General Liability/Casualty - An injury alleged on property. Automobile - Involving a vehicle.
Incident Only

Yes, Incident Only Report

Loss Reporter Information
Reporter Name*

First NameLast Name
Reporter Phone Number*
Reporter Address*

Street Address

Street Address Line 2

CityState

Zip Code
Reporter Email
example@example.com
Relation to Insured*

Insured Information
Name on GuideOne Policy
Insured's Name
Insured GuideOne Policy Number*
*This is not the account number
Policy Issuance State*
What state was policy issued in?
Is Insured Main Contact also the Reporter of the claim?*

YesNo
Insured Main Contact Name*

First NameLast Name
Relation to Insured*
Insured Main Contact Phone Number*
Insured Main Contact Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Insured Main Contact Email
example@example.com

Loss Details
Description of Incident/What Happened*

0/1332
Loss Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Injured Party/Involved Party
Injured Party/Involved Party

First NameLast Name
Injured Party/Involved Party Address

Street Address

Street Address Line 2

CityState

Zip Code
Injured Party/Involved Party Phone

Area CodePhone Number
Injured Party/Involved Party Email
example@example.com

Insured Vehicle Involved
Insured Vehicle Information*
Insured VIN
Insured Damage Description
Did loss involve more than one vehicle?*

YesNo
Was Insured Vehicle being driven at the time of loss*

YesNo

Insured Driver
Insured Vehicle Driver Name

First NameLast Name
Insured Vehicle Driver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Vehicle Driver Phone Number

Area CodePhone Number
Insured Vehicle Driver Email
example@example.com

Third Party Vehicle Information(If Applicable)
Third Party Vehicle
Third Party Damage Description
Third Party Vehicle Owner

First NameLast Name
Third Party Vehicle Owner Address

Street Address

Street Address Line 2

CityState

Zip Code
Third Party Vehicle Owner Phone Number

Area CodePhone Number
Third Party Vehicle Owner Email
example@example.com
Was the owner the driver of the vehicle?

Yes, owner was the driverNo, owner was not the driverVehicle was not being driver at time of loss

Third Party Vehicle Driver
Third Party Vehicle Driver

First NameLast Name
Third Party Vehicle Driver Address

Street Address

Street Address Line 2

CityState

Zip Code
Third Party Vehicle Driver Phone Number

Area CodePhone Number
Third Party Vehicle Driver Email
example@example.com

Any additional information/Attach Documents, photos
Attach damage photos, documents if desired.

Browse Files

Cancelof

Submit
California: For you protection California law requires the following to appear on this form:

“Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.”
The following language is required by law in some states: "Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."
Colorado: "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."
Florida: "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree."
New York: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

New York Auto: "Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation."
Ohio: "Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."
New Jersey: "Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties."
Pennsylvania: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."

Pennsylvania Auto: "Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000."
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New Claim Submission Form