¨-Required information
¨Policyholder:
¨Email Address:
Policy Number, if known:
¨Date of Claim Occurrence (MM/DD/YY):
Time of Occurrence:   AM/PM AM PM

You are filing this claim as an insured or claimant? Insured Claimant (not insured by us)  

Location of Claim (address):
City: State: IN AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL KS KY LA MA MD ME MI MN MO MS MT NC NH ND NE NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Zip code

¨Type of Claim:  Cause of Claim Theft Fire Lightning Wind Water Damage Hail Other Other cause of damage:

¨Description of Incident:
 

Would you like us to contact a contractor for you? Yes/No Yes No
Do you have a repair estimate? Yes/No Yes No      How much is the estimate?
If you have a fax machine, please fax the estimate to 317-888-8897.

¨Were the Police or Fire Department called? Yes/No Yes No    
Department Contacted (e.g. Marion County Sheriff, Greenwood FD)
Report Number:

Additional Comments: