Office Information

Tel: 888-542-9002
Fax: 866-395-0200
Email Us: quotes@selectagency.com

Claim/Incident Report

Please provide contact information of your company, and a short description of the incident, we will contact you shortly for more details. If you prefer the written form, please Click Here.

Please be aware that all fields with a red (*) beside it is a required field. Please contact the office within 2 business days to confirm receipt of the incident report

Insured's Information

* Full Company Name:

* Street Address:

* City:

* State:

* Zip Code:

* Contact Person's Full Name:

* Contact Email Address:

* Contact Phone Number:

Claimant/Injured Party Information

Claimant Full Name:

* Street Address:

* City:

* State:

* Zip Code:

Incident Details

* Date of Incident:

* Time of Incident:

* Place of Incident:

* Date First Heard of the Incident:

* Source of Incident:

* Please provide a brief description of the incident:

*Did anyone prepare a report/statement concerning the incident?** Yes No

*Did you receive correspondence from claimant or an attorney?** Yes No

*Did you receive legal suit papers?** Yes No

*Were there any eye witnesses? Yes No

If yes, please provide their names and contact numbers below:

**If answered "yes," this documentation will be collected at a later date.

It is urgent that you contact Select immediately to confirm receipt and gather all relevant documentation as it will be needed in the review and adjustment of the claim.

Please be advised late notice to the insurance carrier may result in a declination of coverage.