Report a US Claim Online

Please provide the following information to submit your inquiry or notice of claim.

Fields with an asterisk (*) are required.

Please provide the following information to submit your inquiry or notice of claim.

Start by selecting the type of policy you are filing a claim for:

Claim information

Policy number

Employer name

Employer contact email

Employer contact phone number

Claimant name

Claimant address

Claimant phone number

Claimant occupation

Date of injury/loss

Accident location

State of injury/loss

Type of injury

Body part affected

Description of injury/loss

Did the injured worker receive medical attention? Yes No

Where was the medical attention received?

Has the injured worker missed work? Yes No

What was the first day of missed work?

How many days were missed?

Other important information

Claims information

Name

Phone number

Policyholder (individual or business name)

Policy number (providing this number will help expedite the claim set up)

Claimant name (if you are not the claimant)

Claimant phone number

Date of loss

Location of loss

Please provide a description of the loss

Claims information

Name

Phone or mobile number

Your relation to the claim My business sustained damage or property was stolen My propertyvehicle was damaged by someone else I or someone else was injured I am an agent Other type of relationship

Policyholder (individual or business name)

Policy number (providing this number will help expedite the claim set up)

Claimant name (if you are not the claimant)

Claimant phone number

Date of loss

Location of loss (city, state, or territory)

Please provide a description of the loss

General: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Click the link below to view specific fraud warnings by the following states: AL, AK, AZ, AR, CA, CO, DE, DC, FL, HI, ID, IN, KY, LA, ME, MD, MA, MN, NE, NH, NJ, NM, NY, OH, OK, OR, PA, TN, TX, VT, VA, WA or WV. If you are located in one of these states, please take time to review the appropriate warning prior to submitting your claim.

Fraud warnings

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Report a US claim online

Please provide the following information to submit your inquiry or notice of claim.

Claim information

Claims information

Claims information

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