Business Claims

Policy Holder Information

Policy Number:

Primary Contact Person:

Home Phone:

Work Phone:

Where should we contact you: —Please choose an option—HomeOffice

Best time to contact you: —Please choose an option—MorningAfternoonEvening

Claim/Loss Information

Date of Loss or Accident:

Address:

City/Province:

Please provide as much detail as possible regarding the claim in the space provided. (Max. 500 characters) A representative will contact you for additional details.

Police Contacted: —Please choose an option—YesNo

Officer's Name:

Officer's Badge Number:

Report Number:

Did any injuries result from the Loss/Accident: —Please choose an option—YesNo

If yes, please provide names, addresses, phone numbers and the extent of the injuries:

Name of your Broker: