File A Commercial Liability Insurance Claim

CONTACT INFORMATION
Primary Contact
First Last
Mobile Phone
Is It Ok For The Carrier To Text Regarding Your Claim?
Email
Mailing Address
Street Address City State ZIP Code
Best Time To Contact

: Hours

Minutes

AM/PM
INSURED INFORMATION
Is The Insured A Person Or Business?
- Person
- Business
Is The Primary Contact The Named Insured?
- Yes
- No
Name Of Insured
First Last
Name Of Business
Insured's Phone
Insured's Email
Insured's Mailing Address
Street Address City State ZIP Code
Date Of Birth
MM slash DD slash YYYY
Marital Status
- Married | Civil Union
- Single | Divorced | Widowed
Spouse's Name
First Last
Spouse's Date Of Birth
MM slash DD slash YYYY
Spouse's Phone
Spouse's Email
Federal ID Number (If Known)
INSURANCE POLICY INFORMATION
Carrier Information
- Erie Insurance
- Nationwide Insurance
- Travelers Insurance
- State Auto
- UPC Insurance
- Universal Property & Casualty
Policy Number
LOSS INFORMATION
Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
Upload Any Files
Drop files here or

Max. file size: 60 MB.

CONTACT INFORMATION