Tools & Resources | Business Claim Report
If you require immediate assistance with a claim situation, please contact our office or your insurance company directly.

Please take your time filling out this form.

Note that items marked with an asterisk are required.

If you have not been contacted by our office or your insurance company by the next business day after submitting this form, please contact your Broker or Account Manager by telephone to make sure your request has been received.
Policy Holder Information
Policy Number:*
Company Name:
Primary Contact Person:*
Main Phone:*
Work Phone:
Email:
Where should we contact you?
Best time to contact you?
   
Claim / Loss Information
Date of Loss or Accident:
Address:
City / Province:
Please provide as much detail as possible regarding the claim in the space provided below. A representative will contact you shortly.
(Max 255 Words)
Police Contacted?*
Officer's Name:
Officer's Badge Number:
Report Number:
Did any injuries result from the Loss / Accident:
If yes, please provide names, addresses, phone numbers and the extent of the injuries.
Name of your broker:
For security purposes, please write the characters in the image into the box below:
(Case Sensitive)