Claims Form

All the fields marked with (*) are required.

• Name of Policyholder*
• Policy#
• Insured Contact Information*
• Date/time of Loss*
• Location of Loss*
  State
  Zip
• Claim Type---AutomobileBuilder's RiskEquipmentLiabilityMiscellaneousPropertyWorkers Comp.
• Type of Loss*
• Accident Details
• Authority/Case ID#*
• Claimant Information*
• Vehicle Description
• Driver/operator information*
• Equipment Type*

DISCLAIMER: Workers' Compensation claims should be reported directly to the insurance carrier immediately. There is a limited time frame that the carrier has to investigate and pay the claim on the insured's behalf. Please call, email, or fax your insurance carrier in the event of a workers' compensation claim.