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Report a Claim

Loss Type:
 Indicates required field
Agent
Your First Name:
Your Last Name:
Your Email Address:
Accident/Incident Date:
Church / Organization Name:
IB Church ID#:
Street Address:
PO Box:
City:
State:
Zip Code:
-
Did the loss occur at the address above?
Please enter the address where the incident occurred.
Address:
PO Box:
City:
State:
Zip Code:
-

Person to contact regarding this claim:
Contact Title:
Contact Business Phone:
 - 
Contact Mobile Phone:
 - 
Contact Email:

General Description of what is damaged:
How was it damaged:
Has an estimate been completed?
Damage Estimate Amount: $
General description of damages or injury, and how it occurred:
Claimant Name:
Claimant Address:
Claimant City:
Claimant State:
Claimant Zip:
-
Claimant Phone:
 - 
If injury occurred, has there been medical treatment?
Medical Provider Name:
Medical Provider Address:
Medical Provider City:
Medical Provider State:
Medical Provider Zip:
Medical Provider Phone:
 - 
Do you have any additional documentation or photos to provide the adjuster?


Workers Compensation

Auto and workers compensation claims must be reported to your agent or your selected carrier directly. Contact your agent or the Insurance Board for additional assistance.

Auto

Auto and workers compensation claims must be reported to your agent or your selected carrier directly. Contact your agent or the Insurance Board for additional assistance.