Claim Submission

1
Name* This field is required.(Required to identify the policyholder)
First Name
Last Name
2
Email* This field is required.Best email for follow-up
example@example.com
3
Phone Number* This field is required.Best number for follow-up
Please enter a valid phone number.
4
Type of Claim* This field is required.Auto or Home
Please Select
Please Select
Auto
Home
5
Date of Incident* This field is required.When did the incident occur?
Date
Year
Month
Day
6
Description of the IncidentPlease provide a brief summary of what happened.
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Small
Ok
Ok
7
Vehicle InvolvedMake, model, and year of the vehicle.
8
Location of the IncidentWhere did the accident occur?
9
Were there any injuries?
YESNO
10
InjuriesIf yes, describe the injuries
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Small
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Ok
11
Were other vehicles involved?
YESNO
12
Other Vehicles InvolvedIf yes, provide details like the make/model of the other vehicle(s) and insurance information if available
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Ok
Ok
13
Was a Police Report filed?
YESNO
14
Police Report Infoif yes - provide the report number and contact details of the police department.
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Ok
Ok
15
Was the vehicle towed?
YESNO
16
If towed, where is the vehicle currently located?address
17
Is the vehicle driveable?
YESNO
18
Photos of the damagePlease upload any photos of the vehicle damage
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Type of Loss or Damage
Please Select
Please Select
Fire
Water/Flood
Theft
Storm Damage
Other
20
If "Other", please specify
21
Address of the PropertyWhere did the damage occur
22
Description of the Damaged PropertyPlease describe the areas/items that were damaged.
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Ok
Ok
23
Was / Is Emergency Repair Needed?
YESNO
24
If yes, please describe the repair and who performed it.
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Ok
25
Have you contacted any contractors already?
YESNO
26
If yes, provide their contact details
27
Was Law Enforcement involved?For example, if it’s a theft claim, include police report details if applicable
YESNO
28
If yes, please provide infoFor example, if it’s a theft claim, include police report details if applicable
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Ok
Ok
29
Photos of DamagePlease upload any photos of the damage
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
Preferred Method of Contact for Follow-up* This field is required.
Email
Phone Call
Text
31
Any other additional information or notes to share?Any other relevant information to help process the claim
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Ok
Ok
32
Terms and Conditions* This field is required.Notice: by submitting this information to GJIG, it does NOT officially submit your claim to your insurance carrier, but only starts the process with our agency. Once we receive your submission, we will follow up with you promptly to complete the next steps and offer any assistance you may need.
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