Quality Claims Service
"Serving All of Central Illinois"
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About QCS
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Submit Claim
Home
About QCS
Services
Territory
Submit Claim
Electronic Claim Submission Form
Please complete the form below to submit your claim. If you prefer, you can fax your assignment to (309)694-9022. Thank you.
The field marked with (*) are required fields.
*
Company Name
*
Claims Contact/Adjuster
*
Address
*
City/State/Zip
*
Telephone Number
*
Fax Number
Email Address
Claim Number
Policy Number
Date of Loss
*
Insured Name
Address
City/State/Zip
*
Telephone Number
Type of Loss
[Select One]
Property
General Liability
Liquor Liability
Auto Liability
Auto Appraisal
Heavy Equipment Appraisal
Worker's Compensation
Scene Investigation
Police Report
Other
Coverage Information
Replacement Cost
Actual Cash Value
Collision
Comprehensive
Other (Comment in Special Instructions)
Applicable Policy Limit
Deductible (if any)
Claimant Name
Address
City/State/Zip
Telephone
Description of Loss
Special Instructions/Services Required
