File a Claim

Filing a claim on your insurance plan is easy. Simply fill out the form below. Please provide as much information as possible. Press submit to send it to us… It’s that easy.

Claim Information

Name: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Licensed in OH, KY, IN, & IL

Home Phone *

Work Phone *

Fax

Email: *

Hours to call

Preferred Response:

Phone
Email
Text

Are you:

Our Client
Other Party

Policy Number if known

Date/Time of Claim

Description of what happened

please include police / fire called, property damage, injuries, etc

Description of property damage or injuries

Other parties involved

Questions or immediate services needed

Phone