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Make a Claim

You may fill out the form below to notify us about a new claim or if you would rather talk to someone in person, please call 1-800-265-8792.

Personal Information

Your details

* Name of Policyholder/Insured
* Street No. and Name	Apt No.
* City	* Province - Select - Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Québec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Yukon
* Country - Select - Afganistan Albania Algeria Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarous Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Aferican Republic Chad Chile China Christmas Island Cocos Islands Columbia Comoros Congo Congo, Democratic Republic Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equilateral Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibralter Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Laos Lativa Lebanon Lesotho Liberia Libya Lithuania Luxembourg Macau Macedonia Madagascar Maidives Malawi Malaysia Mali Malta Marshal Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldovia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherlands Netherlands Antillies New Calidonia New Zealand Nicaragua Niger Nigeria Niue Norfold Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papau New Guinea Paraguay Peru Phillipines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts Saint Lucia Saint Vincent Samoa San Marino Sandwich Islands Sao Tome Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovak Republic Slovenia Soloman Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay US Minor Outlying Islands Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Fortuna Islands West Sahara Yemen Zambia Zimbabwe	* Postal Code
* Home Phone	* Cell Phone
Work Phone
* Best Number to be reached at - Select - Cell Home Work	* Email Address

Insurance Information

Contact details

Policy Number	Agent/Broker - Select - Bob Darby Bob Moore Burns Insurance Service Chris Demarest Corrigan & Associates Insurance Brokers Dalrymple Insurance Brokers Ltd. E. Bollenbach Insurance Brokers Ed Down Gray Insurance Brokers Inc. Humberview Insurance Brokers Inc. Jeff Holmes Jennifer Brooks Jim Pate Jonathan Richmond Josslin Insurance Brokers Kevin McComb Martin Mason Miguel De Sousa Neil Beaton Roth Nowak Insurance Brokers Sandy File Burns Insurance Service Corrigan & Associates Insurance Brokers Dalrymple Insurance Brokers Ltd. E. Bollenbach Insurance Brokers Gray Insurance Brokers Inc. Humberview Insurance Brokers Inc. Josslin Insurance Brokers Pirie & Burgess Insurance Brokers Inc. Roth Nowak Insurance Brokers
* Type of Loss - Select - Home Auto Agribusiness Commercial Liability	* Location of the Loss
* Details Regarding the Loss	Other Remarks

Auto Claim Information

Auto details

* Is the driver the Policy Holder? Yes No	* Drivers Relation to Insured - Select - Self Family Acquaintance
* Drivers' Name	* Street No and Name
Apt No.	* City
* Country - Select - Afganistan Albania Algeria Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarous Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Aferican Republic Chad Chile China Christmas Island Cocos Islands Columbia Comoros Congo Congo, Democratic Republic Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equilateral Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibralter Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Laos Lativa Lebanon Lesotho Liberia Libya Lithuania Luxembourg Macau Macedonia Madagascar Maidives Malawi Malaysia Mali Malta Marshal Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldovia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherlands Netherlands Antillies New Calidonia New Zealand Nicaragua Niger Nigeria Niue Norfold Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papau New Guinea Paraguay Peru Phillipines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts Saint Lucia Saint Vincent Samoa San Marino Sandwich Islands Sao Tome Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovak Republic Slovenia Soloman Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay US Minor Outlying Islands Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Fortuna Islands West Sahara Yemen Zambia Zimbabwe	Province/State - Select - Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Québec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Yukon
Postal Code/Zip Code	Driver's License Number
* Vehicle Make	* Vehicle Model
* Vehicle Year	VIN Number
* Is the vehicle drivable? Yes No	* Location of the Vehicle now
* How many passengers (excluding driver)	* Were there any injuries? Yes No
If yes, Names of injured	Nature of injuries
Age of injured	Phone Number
* Were other vehicles involved in the accident? Yes No	Name of driver
Insurance Company
Vehicle Make	Vehicle Model
Vehicle Model Year	Drivers License Number
Were there any injuries? Yes No
Location of the vehicle now	Other Remarks

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