Submit a Claim

Statewide Underwriting provides access to a broad base of resources

Protect the damaged property from additional damage.

Notify your agent as soon as possible.

Prepare an inventory list and description of the damaged property.

If repairs must be made before our adjuster can arrive take photos of the damaged property.

All fire claims must be reported to your local Fire Department.

All theft or vandalism claims must be reported to your local Police or Sheriff’s department.

Claim Form

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Insured Information

Policy Number:*

Insured Name:*

Mailing Address:*

Street Address City State ZIP Code

Contact Name:*

Contact Phone:*

Contact Email:*

Agent Information

Agency Name:*

Agency Email*

Agency Contact:

Agency Phone Number:

Comments:*

Loss Information

Date of Loss:*

Location of Loss:*

Address of Loss:*

Street Address City State ZIP Code

Reported to Authorities:

Yes

Reported by:*

Kind of Loss:*