Commercial Property Loss Claim Form

Please fill out the following form and click the submit button. An agent will contact you within 24 hours.

Date of Loss
Time

Contact Information Company Name
First Name Last Name Street City Postal Code Telephone - day Telephone - evening Email
Preferred day

Loss Information Location of loss
Authority contacted
Report #
Violations/Citations
Description of Accident

PROPERTY DAMAGE

Location of loss
Kind of loss
Other
Police of fire dept to which reported
Probable amount entire loss Description of loss and damage

By submitting this form I agree that all of the included information is truthful to the best of my knowledge and I understand that fraudelent claims are illegal and may be prosecuted. Ellis Insurance's acceptance of this form does not constitute confirmation of coverage.