Policy Number
*
Policy Type
*
Residential
Recreational
Name
*
Address Line 1
*
Address Line 2
City
*
State
*
Zip
*
Phone
*
Home
Work
Cell
Phone 2
Work
Home
Cell
Phone 3
Cell
Home
Work
Best time to call
*
Morning
Afternoon
Evening
Communicate via text?
*
Yes
No
You have the option of receiving automated calls and/or text messages from us. Do we have your permission to send autodialed pre-recorded and artificial voice calls and/or text messages to the telephone number that you have provided? Please select Yes or No above.
Email
Date of Loss
*
Time of loss
01
02
03
04
05
06
07
08
09
10
11
12
AM
PM
Location of loss
*
Loss Address 2
Loss City
*
Loss State
*
Loss Zip
*
Briefly describe what happened
*
How many rooms are damaged?
Approximate number of items damaged?
Is home livable?
Yes
No
How many people live in the home?
How many pets live in the home?
How many disabled residents?
Do you need temporary housing?
Yes
No
If residential product:
Was there damage to property owned by someone other than a named insured?
Yes
No
If yes, please enter the other owners information
Other Owners Name
*
Other Owners Address Line 1
Other Owners Address Line 2
Other Owners City
Other Owners State
Other Owners Zip
Other Owners Phone
Description of other owners damaged property
Was anyone injured?
Yes
No
If yes, please enter the injured party's information
Injured Party Name
*
Injured Party Address Line 1
Injured Party Address Line 2
Injured Party City
Injured Party State
Injured Party Zip
Injured Party Phone
Description of injury
Were paramedics called?
Yes
No
Was surgery required?
Yes
No
If motorcycle, collector vehicle, watercraft or snowmobile, please complete:
Who was operating the insured's vehicle?
Is the vehicle operable?
Yes
No
Was the vehicle towed?
Yes
No
Current location of vehicle?
Vehicle Address Line 2
Vehicle City
Vehicle State
Vehicle Zip
Are storage fees being incurred?
Yes
No
Is the vehicle leaking any fluids?
Yes
No
Was another vehicle damaged?
Yes
No
Other Vehicle Owner Name
*
Other Vehicle Owner Address Line 1
Other Vehicle Owner Address Line 2
Other Vehicle Owner City
Other Vehicle Owner State
Other Vehicle Owner Zip
Other Vehicle Owner Phone
What type of vehicle was damaged, description of damages, insurance company, location of vehicle
Was any other property damaged?
Yes
No
Other Property Owner Name
*
Other Property Owner Address Line 1
Other Property Owner Address Line 2
Other Property Owner City
Other Property Owner State
Other Property Owner Zip
Other Property Owner Phone
What type of property was damaged, description of damages, insurance company, location of property
Was anyone injured?
Yes
No
If yes, were they a passenger?
Yes
No
Provide passenger contact information: (i.e. address, phone number, email, etc.)
Describe injuries
Did injuries require surgery?
Yes
No
Was anyone taken to hospital?
Yes
No
Hospital name
Transported via squad or air care?
Were the police and/or fire departments called?
Yes
No
If yes, name of department, officer, report number, if available
Were citations issued?
Yes
No
Phone number for officer or department
Department report or Case Number
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