Your InformationName(Required) First Last Company Name(Required) Phone(Required)Email(Required) Loss InformationName of Insured / File Name PhoneClaim Number Date of Loss MM slash DD slash YYYY Address Street Address City State ZIP / Postal Code Additional InfoIf submitted during the business day, we will contact you within two hours for confirmation of receipt. If you do not hear from us, please contact our office at (618) 687-4900 to ensure your assignment was received.File Upload Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 100 MB, Max. files: 5.
