Report a Claim

Report a Claim

If you would like to report a claim to us directly, please contact us at 408-842-2131, or you are welcome to complete the form below and submit it to our office.

Name of Insured*
Phone Number*
Email*
Address
Street Address Address Line 2 City State ZIP Code
Insurance Company
Policy Number
Date and Time of Loss
Location of Loss
Kind of Loss
Reported To (Fire Dept, Police Dept)
Report Number
Description of Loss
Contact Person
Contact Info (Phone or Email)
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