Business Claim Form

NOTE: Fields marked with * are required.

Contact Information
First Name *

Last Name *
Address (Line 1) *
Address (Line 2)
City *
County *

State *

Zip Code *

Day-Time Phone *
Evening Phone
Email Address *
How would you like us to communicate with you regarding your claim? *
When is the best time to contact you?

Incident / Loss Information
Date of Incident *
Time of Incident (Please include AM or PM) *
Location of Incident *
Incident Reported By *
Authority Contacted (i.e. police, fire, etc.) *
Authority Report Number
Description of Loss or Damage (i.e. fire, water damage, etc.) *

Were Any Witnesses Present? *

If yes, please list.


Were There Any Injuries? *
If there WERE injuries, please provide name, address, phone number and extent of the Injuries in the box.

Description of Property (type, model, etc. *


Policy Information

Is another party responsible for your loss? *

If so, please provide responsible party's first and last name, and address.



Other Involved Parties
Provide Contact Information for ALL other parties involved in the incident.

Additional Comments
Please provide any additional comments on your claim here.

 

 

Copyright ©, Gem City Insurance Inc., 2003