AGENCY CLAIMS FORM

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PLEASE WATCH THIS ~2 MINUTE VIDEO BEFORE SUBMITTING YOUR CLAIM
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Name* This field is required.Which insured should be the point of contact for this loss?
First Name
Last Name
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Phone Number* This field is required.Cell phone where you may best be reached by a claims adjustor.
Area Code
Phone Number
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Email* This field is required.Email where you may best be reached by a claims adjustor
example@example.com
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Address* This field is required.Please list the address where a loss was sustained. If this is regarding auto and you were not parked at a residence then please provide the location to the best of your ability.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Insurance Info* This field is required.What is the name of your insurance carrier and policy #?
Insurance Carrier Name
Policy #
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When Did the Loss Occur* This field is required.Please provide the time/date to the best of your knowledge.
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If Police or Fire Department Were Contacted, What Was the Name of the Department and What is the Report NumberSkip if no report was filed by emergency responders.
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Which Line of Insurance Do You Wish to File a Claim On?* This field is required.
Home
Auto
Watercraft
Commercial
Motorcycle
Flood
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What Kind of Loss Was It?* This field is required.
Fire
Theft
Lightning
Hail
Wind
Flood
Sunken Vessel
Glass
Hit Animal
Collision
Other
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Please a Detailed Description of the Damage Which Prompted You to Start This Claim Submission?* This field is required.You do not need to list all personal property damaged at this time. Your claims adjustor will provide a form to you for that.
Huge
Large
Normal
Small
Ok
Ok
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Have You Take Steps to Prevent Further Loss?* This field is required.i.e. Tarps on holes in the roof to prevent increased water damage
YESNO
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Was there a Auto/Motorcycle/Watercraft Occupied at the Time of the Loss?
YESNO
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If Auto, Was a Child Passenger Restraint System (Child Seat) Installed at Time of an Accident, and In Use by a Child at That Time?
YESNO
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If Occupied, Please Describe Any Injuries For Anyone Involved, the Weather Conditions Present at the Time, and What Happened Leading Up to the Loss.
Huge
Large
Normal
Small
Ok
Ok
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If Loss Was Associated With an Occupied Auto/Bike/Watercraft, What Was the Drivers Name?SKIP IF THIS DOES NOT APPLY
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What Was the Year/Make/Model of the Auto/Bike/Watercraft Driven, and What is the Address Where Can It Be Seen by a Claims Adjustor?
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When Are the Best Times of Day/Week For You to Be Reached?* This field is required.
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Upload Photos Or Other Supporting Documents Here
Drag and drop files here
Select files to upload
Cancelof
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Please verify that you are human* This field is required.
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E-Signature* This field is required.This information is truthful and complete to the best of insureds knowledge. Sign below using a finger, stylus, our mouse.
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