FIRST REPORT OF CLAIM

To report a claim, please complete the information below and forward it to us for handling.
1. Name of Person Reporting Claim:*
2. Insured's Name:*
3. Phone #.
4. Fax #.
5. Email:
6. Type of Claim:(Please check the appropriate box)* Property Automobile Liability Other
In most cases, student injury and workers' compensation claims are reported directly to the insurance carrier.
7. Date of Loss:*
8. Time of Loss:*
9. Location of Loss:*
10. Description of Loss:*
11. Estimated Total Loss:
12. Police Department Name:
Police Phone #.
13. Remarks: (Other parties involved, actions taken follow loss, were police involved)