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CLAIM INFO F REPORT A CLAIM

Online Property Claim Form

REPORT A PROPERTY CLAIM

WESTERN NATIONAL INSURANCE GROUP

* Denotes required fields.

Western National Policyholder Information

Type of Policy

Policy Number *

Western National Policyholder's Name

Address

City

State

Zip

Contact Name *

Contact Phone *

Person Submitting Claim is:

Email of Person Submitting Claim: *

Other Party Information

Name of Other Party

Address

City

State

Zip

Contact Name

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 four injuries, please list below.