To file an Emergency Claim, call (440) 507-1378 and enter you number
  so an agent may contact you immediately.
     
  If you wish to file a claim online, please provide the following 
  information:		  
     
Name of Insured:
Email Address:
Policy #:
Address:
How to contact you:

Home: 

Phone: 

Work: 

Phone: 

Best time:

Date and Time of Loss:

Date: 

Time: 

Type of Claim:             Other: 
Location of Claim:
Description of Claim:

If auto, what vehicle
was involved?:

   

   Who was the driver? 

   Was the driver cited? 

If you have an estimate,
what is the amount and contact person?:

     Amount:   Contact Person: 
                                              Phone #: 

Do you have any information on the other drivers involved? (i.e. names, addresses, phone...)

By submitting this form, I, the claimant agree that all information provided is truthful 
and I understand fraudulent claims are illegal and can be prosecuted by law.