Insurance Claim Submission Form

Are you filling out this form on behalf of someone else?*

YesNo

Is this person a current Rockingham Insurance Customer?

YesNo

Are you a current Rockingham Insurance customer?*

YesNo

Your Name*

First NameLast Name

Name of person you are completing the form for:

First NameLast Name

Address*

Street Address

Street Address Line 2

CityStateZip Code - 5 digitCountry

Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

What is your preferred contact method?*

PhoneEmail

Insurance Company

Policy Number

Name of the Rockingham Insurance customer involved:

First NameLast Name

Rockingham Insurance customer's policy number:

Rockingham Insurance Customer's Vehicle Information