New Claim Submission Form

Name of Person Completing Form

*Full Name

Policyholder/s Information

*First Name:

*Last Name:

*Phone:

*Email:

Add Second Policyholder Information, If Applicable

First Name:

Last Name:

Phone:

Email:

Contractor Information, If Applicable

First Name:

Last Name:

Phone:

Email:

License Number:
This helps us locate you in our system

Loss Details

*Date of Loss:

*Loss Type:WindHailWind & HailWaterFireFloodFallen/Dropped ObjectHurricane

*Damaged Areas:
Please check all that apply
RoofExteriorInteriorBroken TilesCracked TilesCreased ShinglesUplifted ShinglesMissing ShinglesTorn ShinglesBathroomBedroom 1Bedroom 2Bedroom 3Master BedroomLiving RoomDining RoomLaundry RoomGarageHallwayOfficeKitchenCabinetsFloorsWindowsPorchScreensFence

Property Loss Address

*Street Address:

*City:

*Zip Code:

Insurance Information

*Insurance Company:

Policy Number:

Claim Number (If applicable):

Claim Status: OtherNewSupplementDenial
Is there anything else we should know?

File Upload

File size limit 5 MB each

What category best describes the files being uploaded? PolicyPictures of DamageDeclarations PageDenial LetterInsurance DocumentInsurance EstimateContract AgreementOther

*Important
If your insurance policy is available, please upload it here. This will expedite your claim. If it's unavailable, a copy of your Declaration Page can be submitted. However, it is important that we receive a copy of your insurance policy as soon as possible after submitting the form to avoid any delays.