1Named Insured2Contact3Loss4Final Remarks Step 1: Named InsuredI am the*AgentInsuredContactAgency Named Insured* Policy Number* Mailing Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code Primary Phone Number* Phone Type* Home Bus. Cell Secondary Phone Number Secondary Phone Type Home Bus. Cell Email* * indicates required field Same Name Contact Info is the same as Named Insured Name of Contact (First, Middle, Last) Primary Phone Number Primary Phone Type Home Bus. Cell Secondary Phone Number Secondary Phone Type Home Bus. Cell Contact's Mailing Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code Email When to Contact Location of Loss Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code* Date of Loss* DD dash MM dash YYYY Time of Loss Time of Day AM PM Type of LossFireTheftLightningHailFloodWindOtherIf Other, please specify Description of Loss & Damage*Previously Reported Yes No * indicates required field Remarks/Other Insurance (list companies, policy numbers and coverages)Reported By Reported To Disclaimer*Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. By checking this box, I acknowledge that I have read and understand the above disclaimer. Δ OUR INSURANCE COMPANIES American Reliable Insurance Company ® | Diamond State Insurance Company ® | Penn-America Insurance Company ® Penn-Patriot Insurance Company ® | Penn-Star Insurance Company ® | United National Insurance Company ®