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Business Insurance Claim
Home
Report a Claim
Business Insurance Claim
E&S Bonded and P&C Licensed
A Rated Insurers and Specialty Markets
Business Insurance Claim
Sheldon Altschuler
2024-02-01T10:26:15-05:00
Type of Claim
(Required)
- Select -
General Claim
Automobile Claim
Property Claim
Workers Comp Claim
Policy Number
To find your policy number, please visit your
Client Center
. In your policies list, click Actions, then click Report a Claim
Type of Property Loss
(Required)
- Select -
Fire
Theft
Lightning
Hail
Flood
Wind
Other
Other type of Property Loss
(Required)
Business Name
(Required)
Email
(Required)
Phone
(Required)
Date of Loss
(Required)
MM slash DD slash YYYY
Location of Loss
Street Address
City
- Select 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
State
ZIP Code
Location Description
If street location is unknown, please describe the location of the loss to the best of your ability.
Were the police called?
No
Yes
N/A
Police Report Number
Description of Loss
(Required)
Please describe what happened to the best of your ability.
Auto Claim Questions
Driver's Name
(Required)
First
Last
Drivers License Number
Vehicle
(year, make, model, and/or VIN)
Where is the vehicle?
i.e. At home, auto body shop name, friend's house, side of the road, etc.
Describe damage to vehicle
Name of Other Driver
(Required)
First
Last
Other Driver's Drivers License Number
Other Driver's Vehicle
(Required)
(year, make, model, and/or VIN)
Describe damage to other driver's vehicle
Description of Accident
(Required)
Please describe what happened to the best of your ability.
Workers Comp Claim Questions
Name of Injured Employee
(Required)
Date of Injury
(Required)
MM slash DD slash YYYY
Time Employee Began Work
Date Employee Last Worked
MM slash DD slash YYYY
Date Employer Notified
(Required)
MM slash DD slash YYYY
Contact Name
(Optional) Such an union representative, office manager, significant other, etc.
Contact Phone
(Optional)
Type of Injury / Illness
(Required)
Part of Body Affected
(Required)
Equipment, Material, or Chemicals employee was using at time of injury / illness
(Required)
What activity was employee engaged in at time of injury / illness
How did the injury / illness occur?
Date Employee Returned to Work
MM slash DD slash YYYY
If Fatal, Give Date of Death
MM slash DD slash YYYY
Were Safeguards or Safety Equipment Provided?
(Required)
Yes
No
N/A
Were Safeguards / Safety Equipment Used?
(Required)
Yes
No
N/A
Did Injury / Illness Occur on Employer Premises?
(Required)
Yes
No
N/A
Did employee seek medical treatment?
(Required)
Yes
No
N/A
What type of medical treatment facility?
(Required)
Medical Clinic
Emergency Room
Other
How did employee arrive at the medical facility?
(Required)
Drove themself
Another person drove
Taken by ambulance
Taken by helicopter
If employee declined treatment, did they sign a Declination form?
(Required)
Yes
No
Unknown
N/A
Additional Comments or Information
Upload File(s)
Optionally upload any additional files such as copies of drivers licenses, auto ID cards, estimates, forms, doctor summaries, etc.
Drop files here or
Select files
Max. file size: 12 MB.
Who is your agent?
Sheldon Altschuler
Comments
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