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General Claim Report Form
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What is your first name? *
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What is your first name? *
What is your last name? *
*
What is your last name? *
What is your email address? *
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What is your email address? *
Claim contact?
Are you the contact person for this claim?
Yes
No
What is best phone number to contact you on? *
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What is best phone number to contact you on? *
Insured 1 - time frame for contact
When is a convenient time to reach you by phone?
What is the claim contact's first name? *
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What is the claim contact's first name? *
What is the claim contact's last name? *
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What is the claim contact's last name? *
Claim Contact - Email
What is the claim contact's email?
What is the claim contact's phone number? *
*
What is the claim contact's phone number? *
Claim contact - time frame for contact
When is a convenient time to reach the claim contact?
Policy Information
Policy Number
Please enter the policy number, if known.
Insurance Company Name
Please enter the name of the insurance company, if known.
Claim Type
Personal/Business Claim?
Please select the type of claim you would like to report.
Personal Insurance
Commercial/Business Insurance
Personal Insurance Claim Type
What type of personal insurance claim(s) would you like to report? (Select all that apply)
Not sure
Homeowners
Automobile
Watercraft
Valuable Articles/Collections
Identity Theft
Cyber
Personal Liability
Other
Other Personal Insurance Claim Type
Please enter the other type of personal insurance claim you would like to submit.
Homeowners - Cause of Loss
Please select the option below that best describes this Homeowners loss.
My Property Was Damaged By Fire
My Property Was Damaged by Water
My Property Was Damaged By An Act Of Nature
My Property Was Lost
My Property was Stolen
My Property Was Damaged By Another Cause
Someone Else Is Making A Claim Against Me (Liability Loss)
Other
Personal Automobile - Cause of Loss
Please select the option below that best describes this Automobile loss.
My Vehicle Was In An Accident
An Animal Damaged My Vehicle
My Windshield/Auto Glass Are Damaged
Weather Damaged My Vehicle
I Was Injured in an Auto Accident
My Vehicle, Or Its Contents, Were Stolen Or Vandalized
My Vehicle Was Disabled - Towing Needed
Other
Personal Watercraft - Cause of Loss
Please select the option below that best describes this Watercraft loss.
My Watercraft Was In An Accident
An Animal Damaged My Watercraft
Weather Damaged My Watercraft
I Was Injured in a Watercraft Accident
My Watercraft, Or Its Contents, Were Stolen Or Vandalized
My Watercraft Was Disabled - Towing Needed
Other
Valuable Articles/Collections - Cause of Loss
Please select the option below that best describes this Valuable Articles/Collections loss.
My Valuable Articles/Collections Were Damaged
My Valuable Articles/Collections Were Stolen Or Vandalized
My Valuable Articles/Collections Were Lost
Other
Commercial/Business Insurance Claim Type
What type of commercial/business insurance claim(s) would you like to report? (Select all that apply)
Not sure
Business General Liability
Business Property
Workers Compensation
Business Automobile
Directors & Officers Liability
Errors & Omissions/Professional Liability
Cyber Liability
Employers Practices Liability
Other
Other Commercial/Business Insurance Claim Type
Please enter the other type of personal insurance claim you would like to submit.
Business Property - Cause of Loss
Please select the option below that best describes this business property loss.
My Property Was Damaged By Fire
My Property Was Damaged by Water
My Property Was Damaged By An Act Of Nature
My Property Was Lost
My Property was Stolen
My Property Was Damaged By Another Cause
Other
Business Automobile - Cause of Loss
Please select the option below that best describes this Automobile loss.
My Vehicle Was In An Accident
An Animal Damaged My Vehicle
My Windshield/Auto Glass Are Damaged
Weather Damaged My Vehicle
Someone Was Injured in an Auto Accident
My Vehicle, Or Its Contents, Were Stolen Or Vandalized
My Vehicle Was Disabled - Towing Needed
Other
Loss Information
Please provide a brief description of the loss. (Include: description of affected property, incident description, and cause of loss, if known.) *
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Please provide a brief description of the loss. (Include: description of affected property, incident description, and cause of loss, if known.) *
What was the approximate date of the loss? *
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What was the approximate date of the loss? *
MM slash DD slash YYYY
Time of Loss
What is the approximate time this loss occurred?
Hour
:
Minute
AM
PM
AM/PM
Please enter the address where the loss occurred. *
*
Please enter the address where the loss occurred. *
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Loss Injuries?
Were there any injuries as a result of this loss?
Yes
No
Not sure
Injury Description
Please provide a description of the injuries and injured parties.
Damage Estimate?
Do you have an estimate for the repairs?
Yes
No
Awaiting Estimate
Estimate Upload
Please upload a copy of the estimate, if available.
Accepted file types: pdf, Max. file size: 4 MB.
Police Contacted?
Have the police been contacted?
Yes
No
Police Department Name
What is the name of the police department?
Police Officer Name
What is the police officer's name and badge number, if known?
Police department Phone
Enter the phone number for the police department, if known?
Police Report?
Do you have a police report?
Yes
No
Police Report Upload
Please upload a copy of the police report. (PDF only)
Accepted file types: pdf, Max. file size: 4 MB.
Fire Department Contacted?
Was the Fire Department contacted?
Yes
No
Documents and Comments
Please use this field to upload any relevant insurance documents. (Ie. Project contract, Contractor's certificate of insurance, etc...)
Please use this field to upload any relevant documents. (Ie. Estimate, police report, etc...)
Drop files here or
Select files
Max. file size: 128 MB.
Additional Remarks
Please enter any additional remarks in the space below.
Consent
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree *
Ericson Service
860-868-7361
www.ericsoninsurance.com
service@ericsoninsurance.com
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