General Insurance Claim

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required

Please indicate if you are the broker or the policy holder? *

BrokerPolicy Holder

First Name *

Last Name *

Email Address *

Phone *

Policy Number

Insured Person Name or Business Name

GST Registered?

YesNo

Is the insured the preferred contact person? *

YesNo

Date of Loss / Incident *

Loss Location

Third Party Name

Third Party Address

Description of claim *

Upload Supporting Documents or Files

File Upload 1

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File Upload 2

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File Upload 3

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Do you have additional files to upload?

YesNo

Signature

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