Property

Property Loss Claim Form

*Required

Agent Information Section
Agent Name:
Policy Number:

Insured Information Section
Name:*  
Address:

Please provide the following (as many as possible)
Residence Phone:
Business Phone:
Cell Phone:
Email Address:  

Contact Information (if different from named insured)
Name:
Address:
Residence Phone:
Business Phone:
Cell Phone:
Email Address:

Loss Information Section
Date of Loss:*   mm/dd/yyyy
Time Of Loss:*  
Location Of Loss:*  
Type of Loss:
Description of Loss:*  
Police or fire department to which the loss reported, if any.

Reporting Information Section
Your Name:
If not reported by our insured, complete the information below
Your Phone Number:
Your relationship to insured:
Additional Comments if Any:
   
(New Jersey) Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

(Maryland) Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

(Pennsylvania) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.



Report a Claim

You may also contact our Claims Department
by phone at 800.498.0954