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Submit a Claim
Type of Claim
*
General Liability
Automobile
Property
Submitter's Contact Information
Name
*
First
Last
Phone
*
Email Address
Relationship to Insured
*
Attorney
Adjuster
Broker
Claimant
Insured
Parent/Guardian
Store Manager
Other
Who do you represent?
*
Insured
Claimant
Store Number
Manager's Name
Location Address
*
If street address unknown, enter TBD.
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Maine
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Michigan
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South Dakota
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Utah
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Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Claim Information
Same contact information as "submitter" section?
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Name of Insured
*
First
Last
Phone Number
Insured's Email Address
Insured's Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
Date Format: MM slash DD slash YYYY
Time of Incident
:
HH
MM
AM
PM
Location of Incident
*
If street address unknown, enter TBD.
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Description of Incident
*
Police or Fire Department Contacted?
No
Yes
Is there a police or fire report?
No
Yes
Police or Fire Report Number
*
Injured Parties
Was there an injury involved?
Yes
No
Name of injured party
First
Last
Injured party's date of birth
Date Format: 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Description of Injuries
Medical Treatment at the scene? (first aid, ambulance, etc.)
Witness Information
Witnesses?
No
Yes
Names and Contact Information
First Name
Last Name
Phone
Name of any employees who interacted with the injured party at the time of the incident or after the incident
First Name
Last Name
Phone
Was injured party dining?
No
Yes
Was injured party drinking alcohol?
No
Yes
If incident was a slip and fall, were there any foreign materials on the floor?
No
Yes
Was the floor wet?
No
Yes
Was the floor clean?
No
Yes
What were the lighting conditions?
Insured Information
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Accident Information
Date of accident
*
Date Format: MM slash DD slash YYYY
Time of accident
:
HH
MM
AM
PM
Location of accident
Location
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Description of accident
Are there any photographs available?
No
Yes
Photograph Upload
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Authority contacted?
No
Yes
Is there a police report?
No
Yes
Police Report Upload
Witness(es)?
No
Yes
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Description of damages
Claimant Information
Claimant's name
First
Last
Claimant type
Insured Passenger
Claimant Passenger
Car Owner
Pedestrian
Claimant contact number
Claimant's email address
Claimant address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Description of damage
Injured Party's Information
Driver/Passenger
Vehicle Number
Name
Address
City
State
Zip Code
Contact Number
Email Address
Description of Injury
Witness Information
Name
Address
City
State
Zip Code
Contact number
Email address
Any Additional Information/Comments
Details
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File(s)
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