Online Property Claim Form (WNM)


REPORT A PROPERTY CLAIM
WESTERN NATIONAL INSURANCE GROUP
* Denotes required fields.
Western National Policyholder Information
Type of Policy
Policy Number *
WN Policyholder's Name
Address
City	State	Zip
Contact Name *	Contact Phone *
Person Submitting Claim is:
E-mail of Person Submitting Claim: *
Other Party Information
Name of Other Party
Address
City	State	Zip
Contact	Contact Phone
Loss Information
Date of Loss *
Loss Location
Location of Damaged Property *
Description of Accident or Loss*

Injury Information
Was anyone injured? No Yes	If yes, how many?
Name of Injured Party(s)	Description of Injury	Telephone Number




If more than 4 injuries, please list below