Submit a Third-Party Administrator (TPA) Claim

Point of Collection Notice

Step 1 of 8

Type of Claim*
Submitter's Contact Information
Name*
First Last
Phone*
Email Address
Relationship to Insured*
Who do you represent?*
Store/ Unit Number
Contact's Name
Location Address*
If street address unknown, enter TBD.

Street Address Address Line 2 City State ZIP Code

Claim Information
Same contact information as "submitter" section?
- Copy contact information
Name of Insured*
First Last
Phone Number
Insured's Email Address
Insured's Mailing Address
Street Address Address Line 2 City State ZIP Code
Insured's Policy Number

Please write in "N/A" if not applicable
Claimant's Information
Claimant's Name*
First Last
Claimant's Claim Number
Name of Insurance Company
Date of Incident*
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM
Location of Incident*
If street address unknown, enter TBD.

Street Address Address Line 2 City State ZIP Code
Description of Incident*
Police or Fire Department Contacted?
Is there a police or fire report?
Police or Fire Report Number

Injured Parties
Was there an injury involved?
Name of injured party
First Last
Injured party's date of birth
MM slash DD slash YYYY
Injured party's contact number
Injured party's email address
Injured party's mailing address
Street Address Address Line 2 City State ZIP Code
Description of Injuries
Medical Treatment at the scene? (first aid, ambulance, etc.)

Insured Information
Copy contact information as insured?
- Copy
Insured's name*
First Last
Insured's contact number
Insured's policy number
Insured's email address
Insured's address
Street Address Address Line 2 City State ZIP Code

Accident Information
Date of accident*
MM slash DD slash YYYY
Time of accident

: Hours

Minutes

AM/PM
Location of accident
Location City State
Description of accident
Are there any photographs available?
Photograph Upload
Drop files here or

Max. file size: 50 MB.
Authority contacted?
Is there a police report?
Police Report Upload
Max. file size: 50 MB.
Witness(es)?
Witness information
Insured Vehicle Information
Make
Model
Year
VIN Number
Driver's name
First Last
Driver's contact number
Policy number
Driver's email address
Driver's address
Street Address Address Line 2 City State ZIP Code
Description of damages

Claimant Information
Claimant's name
First Last
Claimant type
Claimant contact number
Claimant's email address
Claimant address
Street Address Address Line 2 City State ZIP Code
Claimant's injuries
Claimant Insurance Information
Insurance Policy Number
Insurance Company Name
Claimant Property Damage Information
Owner's name
First Last
Owner's contact number
Owner's email address
Owner's address
Street Address Address Line 2 City State ZIP Code
Description of damage
Injured Party's Information
Injured party
Driver/Passenger Vehicle Number Name Address City State Zip Code Contact Number Email Address Description of Injury

We are here to help

Engle Martin is here to assist and support you with managing your claim experience. Navigating the claim process is easier if you know what to expect. Visit our Claim Resource page for an overview of how to file a claim, important documents to include, and other helpful FAQs to address your most common questions.

+800.818.5619
claims@englemartin.com

Submit a Third-Party Administrator (TPA) Claim

Step 1 of 8

Submitter's Contact Information

Claim Information

Claimant's Information

Injured Parties

Witness Information

Insured Information

Accident Information

Insured Vehicle Information

Claimant Information

Claimant Insurance Information

Claimant Property Damage Information

Injured Party's Information

Witness Information

Any Additional Information/Comments

Upload Document(s) to the Claim (Acord form, photos, policy etc.)

We are here to help

Contact us

Services

Information

Loss Adjusting

Loss Adjusting

Claims Management

Claims Management

Specialty Marine & Transportation

Specialty Marine & Transportation

Specialty Audit Services

Appraisal & Umpire Services

International Capabilities

Specialty Audit Services

Appraisal & Umpire Services

International Capabilities

First Name	Last Name	Phone

First Name	Last Name	Phone

Driver/Passenger	Vehicle Number	Name	Address	City	State	Zip Code	Contact Number	Email Address	Description of Injury

Name	Address	City	State	Zip Code	Contact number	Email address