Submit a Claim

New Loss Assignment

Your assignment will receive immediate attention during normal business hours, 8:30 am through 4:30 pm. (AST), Monday to Friday.

Submitted By

	Name:*
	Company:*
	Telephone:*
	Fax:
	Email:*
	Report To:

Assignment for the attention of

	Location:		*will be sent to head office if nothing selected.
	Adjuster:		*will be sent to head office if nothing selected.

Insured

	Policy Number:
	Claim Number:
	Policyholder:*
	Address 1:
	Address 2:
	City / Town:
	Province:
	Postal Code:
	Phone:
	Fax:
	Email:

Contact Person

	Name:
	Phone:
	Fax:
	Email:

Broker

	Name:
	Telephone:
	Location:

Loss Information

Date of Loss:

Location of Loss:

Handling Instructions:*

Type of Loss:*

Automobile

Property

Liability

Marine - Aviation

Automobile Loss
Vehicle

Make:

Model:

Year:

Serial #:

Driveable:

Yes

License:

Location:

Coverage

	Policy Dates:	From: To:
	Section A:
	Section B:
	Section C:	Collision Deductible:
		Comprehensive Deductible:
		All Perils Deductible:
	Section D:
	Endorsements:
	Loss of Use:	Limit:

Lienholder

Lienholder

Driver

	Name:
	Phone:	(Home) (Work) (Cell)
	Address:
	License Master Number:

Description of Loss* *

Police Report

Claimant / T/P

	Name:*
	Phone:*	(Home) (Work) (Cell)
	Address 1:
	Address 2:
	City / Town:
	License Master Number:

Claimant Vehicle

	Make:
	Model:
	Year:
	Driveable:	Yes No
	Location:
	Insurer:
	Policy No.:

Additional Claimants

Property Loss
Coverage

Policy Dates:

From:

To:

Wording Form: *

Subscribing Companines:*

Building:

Replacement Cost Yes

Contents:

Replacement Cost Yes

A.L.E.

Other:

Co-Insurance:

Mortgage / Lienholder:

Deductible:

Type of Loss:

Other:

Description of Loss:*

Claimant / T/P

	Name:*
	Phone:*	(Home) (Work) (Cell)
	Address 1:
	Address 2:
	City / Town:
	License Master Number:

Claimant Vehicle

	Make:
	Model:
	Year:
	Driveable:	Yes No
	Location:
	Insurer:
	Policy No.:

Additional Claimants

Liability Loss
Coverage

	Policy Dates:	From: To:
	Wording Form:*
	Limit:
	Voluntary Medical coverage Limit:
	Voluntary Property coverage Limit:
	P.D. Deductible:
	Type of Loss:
	Description of Loss:*

Claimant / T/P

	Name:*
	Phone:*	(Home) (Work) (Cell)
	Address 1:
	Address 2:
	City / Town:
	License Master Number:

Claimant Vehicle

	Make:
	Model:
	Year:
	Driveable:	Yes No
	Location:
	Insurer:
	Policy No.:

Additional Claimants

Marine - Aviation Loss
Coverage

Policy Dates	From: To:
Wording Form:*

	Amount $	Deductible	Co-Ins%
Hull:
Electronics:
Other:

Mortgage / Lienholder
Type of Loss:
Location of the vessel / plane:
Description of Loss:*

Claimant / T/P

	Name:*
	Phone:*	(Home) (Work) (Cell)
	Address 1:
	Address 2:
	City / Town:
	License Master Number:

Claimant Vehicle

	Make:
	Model:
	Year:
	Driveable:	Yes No
	Location:
	Insurer:
	Policy No.:

Additional Claimants