Commercial Claim

Important note: Details entered here will not be submitted to your insurance company automatically, they will just be sent into our office for processing. Once received your account manager will contact you within three business hours to review.

Policy Holder Information
Policy Number:
Primary Contact Person:
Home Phone:
Work Phone:
Where should we contact you:
Best time to contact you:
Claim/Loss Information
Date of Loss or Accident:	Today
Address:
City/Province:
Please provide as much detail as possible regarding the claim in the spece provided below. A representative will contact you shortly. (Max 500 characters):
Police Contacted:	YesNo
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:
Security code: