Claim Report Forms – Business | Zehr Insurance Brokers Ltd.

Claim Report Forms – Business

In an emergency claim situation, please contact our office directly.

*(denotes required field)

E-Mail Address:

--- Policy Holder Information ---

Policy Number: *

Company Name

Primary Contact Person: *

Main Phone: *

Work Phone:

Where should we contact you?

Best time to contact you?

--- Claim / Loss Information ---

Date of Loss or Accident:

Address:

City / Province:

Please provide as much detail as possible regarding the claim in the space provided below. A representative will contact you shortly. (Max 255 Words)

Police Contacted? *

Yes No

Officer's Name:

Officer's Badge Number:

Report Number:

Did any injuries result from the Accident?

Yes No

If yes, please provide names, addresses, phone numbers and the extent of the injuries.

Name of your broker:

CAPTCHA Code: *