Fields with an * are required to submit a claim  
 
What type of name do you need to enter?* Personal Commercial
 
 
First Name:* Middle Name:
Last Name:* Suffix: Support table "NAME_SUFFIX_LIT" not found.
 
Insured Name:* DBA Name:  
 
 
Address:*  
City:* State:* Support table "STATE_CODE_LIT_PO" not found.
Postal Code:*  
 
 
Daytime Phone:* Extension:
Evening Phone: Extension:
 
 
Insured E-mail Address:
 
 
Additional Contact Information:

 
 
Location of Loss (Street Addr):*    
City:*  State:* Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
Policy Type:* Support table "LIABILITY_SYMBOL_LIT" not found. Policy Number:
Date of Loss:*
 
 
Authority Contacted:* Yes No
 
 
Description of Loss:*

 
Yes No   Is there property damage to report at this time? *
Property Damage 1 of 1
 
 
Property Owner's Name:*    
 
 
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
 
 
Daytime Phone: Extension:
Evening Phone: Extension:
 
 
Property Description:
Estimate Amount:
Where Can Property Be Seen: When Can Property Be Seen:
 
 

 
Yes No   Are there any injuries to report at this time? *
 
 
Injured Information 1 of 1
 
 
Name:
 
 
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
 
 
Daytime Phone: Extension:
Evening Phone: Extension:
 
 
Age:
Sex: Support table "driver_sex_lit" not found.
Occupation:
 
 
Injury Description:

Fatality: Yes No
 
 

 
Yes No   Any witnesses known at this time? *
 
 
Witness 1 of 1
 
 
Name:
 
 
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
 
 
Daytime Phone: Extension:
Evening Phone: Extension:
 
 
Location of Witness: Support table "witness_loc_lit" not found.
 
 

 
Additional Notice of Loss Comments:

Agency Name: Agency Phone Number:

 
 
 Fraud Warning

Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil and criminal prosecution for insurance fraud.