1. Insured & Policy Information

Named Insured / Business or Association Name *

Policy Number

Insurance Carrier

Line of Business

2. Loss Information

Date of Loss *

Property Address / Location Where the Claim Occurred *

City *

State *

Country

Postal Code

Kind of Loss *

If Other, please describe:

3. Insured Claim Contact

Contact Name *

Title / Relationship to Named Insured

Phone *

Email *

Preferred Method of Contact

Phone

4. Claimant / Other Party Information

Claimant / Other Party Name

Company / Organization

Phone Number

Email Address

5. Description of Loss / Allegation

Include as much information as possible regarding the circumstances of the loss, property damage, injuries, parties involved and/or any allegations being made.

Please describe what happened. *

Were there any injuries?

Yes

Unknown

If yes, please describe the injuries, if known:

Were police, fire, emergency services or other authorities contacted?

Yes

Unknown

Department / Agency:

Report Number:

6. Supporting Documents

Please upload any available documents relating to the claim. Helpful documentation may include:

Photos or videos of the damage or accident scene
Legal documents, demands, summonses or complaints
Police, fire or incident reports
Estimates, invoices or repair documentation
Correspondence from a claimant, attorney or other party
Any other documents you believe may be relevant

Upload Documents & Photos

Click to upload

Have you received legal documents?

Yes

IMPORTANT: If you have received a summons, complaint, lawsuit, demand or other time-sensitive legal document, please upload it with this form and contact Coldbrook Insurance Group immediately.

7. Additional Information

Is there anything else we should know about this claim?

Before You Submit

I certify that the information provided is accurate to the best of my knowledge. *

Yes, I certify that the information provided is accurate to the best of my knowledge.

Important Claim Notice

If this is an emergency, please contact the appropriate emergency services and take reasonable steps necessary to protect people and property from further injury or damage.

Do not delay forwarding any lawsuit, summons, complaint, demand letter or other time-sensitive legal document.

Submission of this form does not guarantee coverage, constitute a determination of coverage, or confirm that the insurance carrier has accepted or received the claim. Coverage is subject to the terms, conditions, limitations and exclusions of the applicable insurance policy. Claim and coverage determinations are made by the insurance carrier.

A representative of Coldbrook Insurance Group may contact you if additional information is needed.