Insured

Named Insured
Policy#
Insured’s Address
Address 2
City
—Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code

Contact Information

Contact Person for Insured
Phone #
Cell Phone #
Email Address*
Name of Person reporting claim
Phone #
Cell Phone #
Email Address

Loss Information

Claimant name
Brief description of claim
Date the claim was received by the insured

Remarks

Comments
* Please submit all claim documents (e.g., Charge of Discrimination, Due Process Hearing Request, attorney’s letter, Summons & Complaint, Notice of Tort Claim, or any similar document). Failure to submit relevant documents may delay the processing of your claim.