Claim Status Inquiry Form

First Name *

Last Name: *

Address *

City *

State *
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ZIP *

Phone *

Email *

Were there any injuries as a result of this incident?
InsuredClaimantService providerOther

Claim Number *

Date of Incident *

Type of Claim (e.g., Auto, Property, Liability)

Please indicate how you would like us to contact you with the status of your claim. *

PhoneEmailPostal Mail

If you have any specific questions regarding your claim or any additional information you believe might be relevant, please provide them below

Please upload any photos or videos related to the incident, as well as images of the vehicles involved. Additionally, include pertinent documents such as police reports, invoices, and any other relevant materials.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

I hereby declare that the information provided in this form is true and accurate to the best of my knowledge.
I understand that this form will become a part of the claim file.