Report a Claim

Many of the companies we represent have 24-hour reporting numbers. You may report your claim direct to the insurer by calling the numbers found here.

If you would like to report a claim to us directly, please contact us at 800.966.2155, or you are welcome to complete the form below and submit it to our office.

Name of Insured *

Insured Phone Number *

Insured Street Address *

Insured City *

Insured State *

Insured Zip *

Insurance Company *

Policy Number *

Date and Time of Loss *

Location of Loss *

Kind of Loss *

Reported To (Fire Dept, Policy Dept)

Report Number

Description of Loss *

Contact Person *

Contact Info (Phone or Email) *