Report a Claim by Completing the Form Below

What is the cause of the Loss? * Earthquake Explosion Water Damage Glass Breakage Malicious Mischief and Vandalism Riot and Civil Commotion Fire Wind Structural Failure Snow/Ice Burglary

Date of Loss (mm-dd-yyyy) *

Date Loss Reported (mm-dd-yyyy) *

Policy Number Associated with Loss *

Name of Insured on Policy *

Loss Address *

Loss City *

Loss State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Loss Zip Code *

Description of your Damages *

Name of person reporting the claim *

Relation of Person Reporting the Claim to Insured * Self Relative Friend Agent Attorney Spouse Domestic Partner Public Adjuster Injured Party Other

Insured/Policyholder Email *

Policyholder Phone *

Agent Email

Main Contact Phone (if different than policyholder)

Main Contact Email (if different from policyholder or agent)

Comments