Web Reported Claim

Begin The Claim

What is your relationship to the claim?

Policyholder Agent Claimant Attorney Other

Company Name

Policy #

Your First Name*

Your Last Name*

Your Address*

Your City*

Your State*

Your Zip*

*Preferred method of contact

Contact Phone

Contact Email

Policyholder

Company Name*

First Name

Last Name

Address

City

State

Zip

Home Phone

Work Phone

Extension

Cell Phone

Preferred Contact

Policy #

Claim Details

Date of Loss*

Time of Loss

*Address or Intersection of Accident

*City

*State

Zip

*Briefly describe what happened in the incident

Were local authorities notified or on the scene?

Yes No

Agency Name/Precinct

Report Number

Officer/Authority Name

Badge Number

Other Party

Were other parties involved?

Yes No

*First Name

*Last Name

*Address

*City

*State

*Zip

Home Phone

Work Phone

Extension

Cell Phone

How were they involved?

In relation to what Vehicle?

Was this person injured?

Yes No

If yes, please describe the injuries

You have indicated there were injuries as a result of this loss – please immediately call 1-855-LOG-LOSS or 1-855-564-5677 to report the claim

Summary

Your claim is now ready to submit.

Is there anything else that you would like to note?

Attachments

+ Add files...