Claims Form

Property Information
Date of Loss

MonthDayYear
Date
Time of Loss (if known)
Property Address with Loss (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Property
If Other Please Specify
Claim Type (Select all that apply)
If Other Please Specify
Brief Description of Loss
Were there any injuries involved?
If Yes, please describe (persons injured, nature of injuries, any medical treatment received, etc.)
Evidence and Supporting Documents
Photos Attached
Videos Attached
Repair Estimate Attached
Upload Evidence and Supporting Documents

Cancelof

Additional Questions
Customer Serived Filled Out Form?
Any additonal notes or comment
Please verify that you are human*
Client Claim Reporting Authorization Form
I hereby authorize RMB Insurance Agency, LLC to assist in reporting a claim to my insurance carrier based on information provided by me.
I understand this authorization does not guarantee coverage or approve any claim. The insurance carrier will make all final decisions.

I hereby declare that the information provided above is accurate and complete to the best of my knowledge. I understand that any false or misleading information may result in denial of this claim.
Type a question

Powered by Jotform SignClear
Should be Empty:

Personal Information