Welcome To Universal Risk

Claim Reporting Form

Please enter your claim loss information in the form provided below, for us to be able to service you better, thank you.


-•- Insurance Company Section -•-
1).	Name of Insurance Company
2).	Insurance Company Address
3).	Insurance Company City
4).	Insurance Company State
5).	Insurance Company Zip
6).	Insurance Company Phone number
7).	Insurance Company Policy Number
8).	Insurance Company Claim Number
9).	Insurance Company Contact Person
10).	Insurance Company Contact Email
11).	Agent Name
12).	Agent Mailing Address
13).	Agent City
14).	Agent State
15).	Agent Zip
16).	Agent Phone Number
17).	Agent E-Mail
-•- Insured Section -•-
18).	Insured Last Name
19).	Insured First Name
20).	Insured Mailing Address
21).	Insured City
22).	Insured State
23).	Insured Zip
24).	Insured Home Phone
25).	Insured Work Phone
26).	Insured Cell Phone
27).	Insured E-Mail
-•- Claimant Section -•-
28).	Claimant Last Name
29).	Claimant First Name
30).	Claimant Mailing Address
31).	Claimant City
32).	Claimant State
33).	Claimant Zip
34).	Claimant Home Phone
35).	Claimant Work Phone
36).	Claimant Cell Phone
37).	Claimant E-Mail
-•- Loss Section -•-
38).	Date Loss Occured
39).	Time loss Occured
40).	Loss Mailing Address
41).	Loss City
42).	Loss State
43).	Loss Zip
44).	Loss Description
-•- Damage / Injury Section -•-
45).	Types of Property Damages Sustained	Building Contents Business Interruption Other
46).	Types of Injuries Sustained
47).	Additional Comments
-•- Reporter Section -•-
48).	Name of Person Reporting Loss
49).	Phone Number of Person Reporting Loss

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