If this is a Homeowners Claim, and your Home or Property has sustained damage, please take whatever steps necessary, in the interim, to secure your home or property from further damage. An adjuster will contact you, usually within 24-48 hours. Please be sure to leave a daytime and evening phone number.

If this an Auto Claim, and your car is not driveable, please have it towed to the nearest repair center for an estimate. If your car is now at home, please wait for an adjuster to call before taking it in for repairs. If you, or anyone else has been injured, please seek medical attention immediately. It is not necessary to wait for an adjuster to call. Your physical well-being, and that of your passengers, takes precedence. Thank you.

IF AUTO LOSS
Driver of Vehicle
Vehicle Involved (year, make, model)
Where did loss occur?

Were there any injuries? Yes No
If yes, please provide details...

Type of Auto Loss (Select all that apply)
Collision Theft Vandalism Deer Hit Injury

IF HOME LOSS
Type of Home Loss (Select all that apply)
Fire Theft Weather Water Personal Injury

Please provide all known information regarding
the circumstances of this loss:

Any additional information regarding other
drivers or details that you may want to provide?

Your Name
Day Phone () - Eve Phone () -
Email