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Submit a Claim

Please select below the type of Claim you would like to submit and then fill the corresponding form. Afterwards you will receive a Reference Number via email.

automobile

property

workers compensation

auto glass

liability

First Notice of Loss Automobile

Reported By:
Name (Reported By)*
First Last
Phone (Reported By)*
Phone Type
Email Address (Reported by)
Your Relationship to Accident
- Insured
- Other
Other Relationship
Loss Information:
Policy Number*
Zip Code & County of Loss*
Date of Loss*
Time of Loss / Accident*

: HH

MM

AM/PM
Insured Information:
Name (Insured)*
First Last
Phone (Insured)*
Phone Type
Address
Street Address Address Line 2 City State ZIP Code
Insured Vehicle:
Year
Please enter a number from 1950 to 2023.
Make*
Model*
VIN No.
Damaged Area
Is Car Drivable?
Current Vehicle Location Address
Street Address Address Line 2 City State ZIP Code
Driver's Name
First Last
Phone (Driver)
Phone Type
Accident Information:
Address Where Accident Occurred
Street Address Address Line 2 City State ZIP Code
Description of How Accident Happened*
Other Vehicle's Information:
Year
Please enter a number from 1950 to 2023.
Make
Model
VIN No.
Damaged Area
Other Vehicle Owner's Information:
Name (Other Vehicle)
First Last
Phone (Other Vehicle Driver)
Phone Type
Address (Other Vehicle Driver)
Street Address Address Line 2 City State ZIP Code
Please add any police report information, other insurance information (Company name, claim number, policy number and contact information)
Attachments
Please add any and all relevant images or files to your claim. This form can only accept image files and pdf files. These are files with file extensions of .jpg, .jpeg, .png, .gif, .pdf and .bmp. If you have other critical files to submit, you can discuss that with your claims agent directly after submission of this form. For help, contact us. Total size of files uploaded cannot exceed 4MB. If you have images larger, you will be able to send them directly to your claim agent during the process.
Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, eps, bmp, Max. file size: 10 MB.
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First Notice of Loss Property

Reported By:
Name (Reported By)*
First Last
Phone*
Phone Type
Email (Reported By)
Your Relationship to Loss
- Insured
- Other
Other Relationship to Loss
Loss Information:
Policy Number*
Date of Loss*
Time of Loss / Accident*

: HH

MM

AM/PM
Insured Information:
Insured Name*
First Last
Insured Phone Number
Phone Type
Insured Email Address
Insured Address
Street Address Address Line 2 City State ZIP Code
Loss Location:
Address Where Loss Happened
Street Address City State ZIP Code
County of Loss
Description of how Loss Happened*
Description of Damages
Please include any information from police report or fire department response.
Attachments
Please add any and all relevant images or files to your claim. This form can only accept image files and pdf files. These are files with file extensions of .jpg, .jpeg, .png, .gif, .pdf and .bmp. If you have other critical files to submit, you can discuss that with your claims agent directly after submission of this form. For help, contact us. Total size of files uploaded cannot exceed 4MB. If you have images larger, you will be able to send them directly to your claim agent during the process.
Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, eps, bmp, Max. file size: 10 MB.
CAPTCHA

First Notice of Loss Liability

Reported By:
Name (Reported By)*
First Last
Phone*
Phone Type
Email
Your Relationship to Loss
- Insured
- Other
Other Relationship
Loss Information:
Policy Number*
Date of Loss*
Time of Loss / Accident*

: HH

MM

AM/PM
Insured Information:
Insured Name*
Insured Phone Number
Phone Type
Insured Address
Street Address Address Line 2 City State ZIP Code
Loss Information:
Loss Address
Street Address City State ZIP Code
County of Loss
Cause of Loss
Description of how Loss Happened*
Property Owner or Injured Person:
Name (Property Owner or Injured)
First Last
Phone*
Address
Street Address Address Line 2 City State ZIP Code
Please include any police report information, or other insurance information (Company name, policy and/or claim number, phone number etc.)
Attachments
Please add any and all relevant images or files to your claim. This form can only accept image files and pdf files. These are files with file extensions of .jpg, .jpeg, .png, .gif, .pdf and .bmp. If you have other critical files to submit, you can discuss that with your claims agent directly after submission of this form. For help, contact us. Total size of files uploaded cannot exceed 4MB. If you have images larger, you will be able to send them directly to your claim agent during the process.
Drop files here or

Accepted file types: jpg, jpeg, png, bgif, pdf, eps, bmp, Max. file size: 10 MB.
CAPTCHA

First Notice of Loss Workers Compensation

Reported by:
Name (Reported By)*
First Last
Primary Phone Number*
Phone Type
Email Address (Reported By)
Your Relationship to Incident
- Employer
- Employee
- Other
Other Relationship to Incident
Loss Information:
Policy Number*
Date of Injury*
Time of the Injury*

: HH

MM

AM/PM
Employer Information:
Employer Name*
Employer Phone Number
Employer Address
Street Address Address Line 2 City State ZIP Code
Contact Name*
Contact Phone Number
Phone Type
Contact Address
Street Address Address Line 2 City State ZIP Code
Address Where Loss Occurred
Street Address Address Line 2 City State ZIP Code
County of Loss
Description of how Injury Happened*
Injured Employee Information:
Name (Injured)*
First Last
Phone Number (Injured)
Phone Type
Email Address (Injured)
Address (Injured)
Street Address Address Line 2 City State ZIP Code
Date of Birth (Injured)
MM slash DD slash YYYY
Social Security Number (Injured)
Date of Hire (Injured)
MM slash DD slash YYYY
Job Title (Injured)*
Type of Employee (Injured)
- Full Time
- Part Time
Injury Information:
Injury Description - Be as detailed as possible, including left or right body part where applicable
Was there Medical Treatment?
- Yes
- No
Name of Provider for Initial Treatment
Will the person lose time from work?
- Yes
- No
Is this related to an Auto Accident?
Please provide police department name and incident number, any other insurance company information (name, policy or claim number, contact info, etc)
Attachments
Please add any and all relevant images or files to your claim. This form can only accept image files and pdf files. These are files with file extensions of .jpg, .jpeg, .png, .gif, .pdf and .bmp. If you have other critical files to submit, you can discuss that with your claims agent directly after submission of this form. For help, contact us. Total size of files uploaded cannot exceed 4MB. If you have images larger, you will be able to send them directly to your claim agent during the process.
Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, eps, bmp, Max. file size: 10 MB.
CAPTCHA

Submit a Claim

First Notice of Loss Automobile

Reported By:

Loss Information:

Insured Information:

Insured Vehicle:

Accident Information:

Other Vehicle's Information:

Other Vehicle Owner's Information:

First Notice of Loss Property

Reported By:

Loss Information:

Insured Information:

Loss Location:

First Notice of Loss Liability

Reported By:

Loss Information:

Insured Information:

Loss Information:

Property Owner or Injured Person:

First Notice of Loss Workers Compensation

Reported by:

Loss Information:

Employer Information:

Injured Employee Information:

Injury Information: