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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 fields marked with (*) are required fields.

*

Company Name
 * required

*

Claims Contact/Adjuster
 * required

*

Client Address
 * required

*

Client City/State/Zip
 * required

*

Client Telephone Number
 * required

*

Client Fax Number
 * required
 
Client Email Address
 
Claim Number
 
Policy Number
 
Date of Loss

*

Insured Name
 * required
 
Insured Address
 
Insured City/State/Zip

*

Insured Telephone Number
 * required
 
Type of Loss
 
Coverage Information
Replacement Cost
Actual Cash Value
Collision
Comprehensive
Other (Comment in Special Instructions)
 
Applicable Policy Limit
 
Deductible (if any)
 
Claimant Name
 
Claimant Address
 
Claimant City/State/Zip
 
Claimant Telephone
 
Description of Loss
 
Special Instructions/Services Required