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Claim: Input
Matthias Allred
2021-07-06T11:23:38-06:00
Claim Intake Form
Please provide details about your claim.
"
*
" indicates required fields
1
Type of Claim
2
Contact Details
3
Claim Details
Type of Claim
*
Home
Auto
Other
Full Name
*
First
Last
Phone
*
Email
*
Home Claim Information
Date of Loss
*
MM slash DD slash YYYY
Time of Loss
*
Insurance Carrier
*
Select One
Other/Not Sure (use Notes Section)
ASI
American Modern
Auto-Owners
Berkshire Hathaway
Bristol West
Cat Coverage
Chubb
Dairyland
Foremost
GainsCo
Hagerty
Kemper Preferred
Kemper Specialty
Liberty Mutual
MetLife
Nationwide
Mutual Of Enumclaw
Progressive
SafeCo
StateAuto
Stillwater
Sublimity
The Hartford
Travelers
United Heritage
United Insurance Group
Vacant Express
Personal Umbrella
Policy Number
(if available)
What Best Describes The Cause Of The Incident
*
My Property Was Damaged By Fire Or Water
My Property Was Damaged By An Act Of Nature (Wind, Hail, etc)
My Property Was Lost Or Was Stolen In A Criminal Act
My Property Was Damaged By Another Cause
Someone Is Making A Claim Against Me (Liability Loss)
Something Else Happened
Auto Claim Information
Date of Loss
MM slash DD slash YYYY
Time of Loss
*
Driver Involved
*
Our Insured's Vehicle Involved
*
Location of Incident (address or best description of location)
*
Other Claim Information
Date of Loss
*
MM slash DD slash YYYY
Time of Loss
*
Use Notes Section to list who was involved, where it happened, and what happened.
Notes - What Happened?
*
Documentation
Please upload any supporting documentation regarding your claim, such as a police report, pictures, etc.
Drop files here or
Select files
Accepted file types: pdf, pdf, jpg, jpeg, jpeg, jpg, png, png, Max. file size: 50 MB, Max. files: 10.
Action
*
Please file this claim
No Action Needed. Claim is already filed, just notifying you.
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Admin Use Only
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Form Category
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Form Name
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Agency Name
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AMS ID
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CRM ID
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Internal Use
Yes
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