Claim Form — Send Us Information On New Or Ongoing Claims

Use this form to send us claim information. Send what you can now, send the rest later if necessary — we’ll match it by the insured’s name. Upload photos, videos, and documents here.

Please provide the primary insured's information; we'll ask for additional information if needed.

Insured's Name

Insured's Mobile Phone

Insured's Alternate Phone

Insured's Email

Insured's Current Location

Policy #

Claim #

Policy Type

Cause of Loss

Date of Loss

The Coverage C Limit and Amount Previously Paid by the insurance company help us calculate a target amount for the claim.

Coverage C Policy Limit

Amount Previously Paid

Loss Location: Street, City, State

Insurance Company

Adjuster's Name

Adjuster's Phone

Adjuster's Email

Notes