Submit a Claim
Norgaard Agency, Inc.
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Email:
example@example.com
Policy Type (Auto, Home, Rec Veh, etc.):
Date of Loss:
Time of Loss:
Location of Incident/Loss:
What drivers, if any, were involved?
What vehicle(s) were involved (if applicable)?
Description of Incident/Loss:
Were the authorities called (if applicable):
What party was at-fault? (if applicable):
Have you already obtained an estimate to repair damages? If so, please list the company you have contacted.
Additional Information or Details you want to share with your agent:
Form completed by:
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Please verify that you are human
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