Report a Claim Form
We understand that experiencing a loss can be stressful. Please complete this form to report your claim. A Gold Key Insurance representative will contact you shortly to assist you through the process.
1. Policyholder Information:
Name
First Name
Last Name
Policy number
Email
example@example.com
Phone Number
Please enter a valid phone number.
2. Loss Information:
Date of Loss
-
Month
-
Day
Year
Date
Time of Loss
Hour Minutes
AM
PM
AM/PM Option
Location of Loss
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Loss(Provide a detailed description of what happened and the extent of the damage)
3. Type of Claim:
Select one
Auto Accident
Home Damage (Fire, Theft, Water Damage, etc.)
Business Property Damage
Other
4. People Involved:
Were there any injuries?
Yes
No
Names and contact information of any other individuals involved:
Police Report Filed?
Yes
No
If yes, please provide the report number:
5. Witnesses:
Were there any witnesses?
Yes
No
Names and contact information of any witnesses:
6. Additional Information:
Is the property safe and secure?
Yes
No
Have you taken any steps to mitigate further damage?
Yes
No
If yes, please explain
Upload any file that is relevant to the claim
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