Online Claims Documentation/Information Submission

The general purpose for this Claims Documentation Form is to provide you with an easy to use way of supplying the claims process with a written description of exactly what happened, in your own words.

Providing this information does NOT replace the need for a claims adjuster to personally contact you.  It does however allow you to document, in great detail, what has occurred for your file and records within our office.

In the event of a natural disaster (i.e. tornado, flood, storm, fire, etc..) where basic services have been interrupted, this form further allows us to receive information from you that could otherwise be difficult to receive if our telephone lines were consistently busy due to the disaster. In such an instance try to remember how far reaching the Internet can be... If you can get to a computer with Internet access, you can quickly use this method to communicate your situation with us.

Please remember to: Always call first to report your claim.

Red Identifiers Indicate A Required Field

Your Full Name:
Day Phone:
Evening Phone:
E-mail Address:
Would you like us to contact you concerning the information contained in this form:
If you answered "YES" to the previous question what is your preferred Method Of Contact:

Ins. Co. Name:
Policy #:
Have you already spoken with the Insurance Company about your claim:
If the Insurance Company issued you a Claim #, can you tell us 
what it is:

Claim Type:
Date Of Incident: mm/dd/yy
Vehicle Involved:
(if any)


(If Applicable)


Please be as specific in detail as you wish.

Click "Submit Form" to send your completed information.




830 Hartford Road    Manchester, Connecticut 06040    (860) 646-6050
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