Report a Claim

Report a Claim

Thank you for contacting Genoteq. To report a new claim, please fill out the fields below:
Reported By:
Your Full Name:*

First NameLast Name
Your Email Address:*
example@example.com
Your phone number:*
Please enter a valid phone number.
Your Role:*
Our policy number: *

Loss Details
Date of Loss:*

MonthDayYear
Accident State:*
Loss Description:*

0/250

Our Policyholder's Vehicle Details
Year of Our Vehicle:
Make of Our Vehicle:
Model of Our Vehicle:
VIN of Our Vehicle:*
License Plate for Our Vehicle:
Name of the driver for Our Vehicle:*

First NameLast Name
Any known injuries in Our Vehicle?*

Other/Second Vehicle
Year of Other/Second Vehicle:
Make of Other/Second Vehicle:
Model of Other/Second Vehicle:
VIN of Other/Second Vehicle:
Insurance Company for Other/Second Vehicle:
Policy Number for Other/Second Vehicle:
Claim Number for Other/Second Vehicle:
Any known injuries in the Other/Second Vehicle?

Additional Loss Details
Has a police report been filed?
Does this loss involve a ride-sharing platform?
Which ride-sharing platform was involved?
Has this loss also been reported with another carrier?
Has this loss also been reported to a ride-sharing platform?
Any additional information you'd like to provide?

0/250

Please post any attachments related to this claim here:

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