report a claim

Submitted by:

First Name (required)

Last Name (required)

Company (required)

Address (required)

City (required)

Province (required)

Postal Code (required)

Country (required)

Telephone (required)

Your Email (required)

Insured Information:

Insured First Name (required)

Insured Last Name (required)

Person to Contact (required)

Address (required)

City (required)

Province (required)

Postal Code (required)

Country (required)

Telephone (required)

Policy Number (required)

Broker Information:

Company Name (required)

Contact Name (required)

Loss Information:

Date of Loss(required)

Type of Loss:
 Liability Property Auto Accident Benefits Bodily Injury TPA

Location (required)

Loss Description

Name of Injured Party (as applicable)

Injury/Damage Sustained

Special Handling Instructions