Name: Delucia Insurance Agency
Price range: $$

Comments

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Type of Claim*

Policy Number

To find your policy number, please visit your Client Center. In your policies list, click Actions, then click Report a Claim

Type of Property Loss*

Other type of Property Loss*

Business Name*

Email*

Phone*

Date of Loss*

Location of Loss

Street Address City State ZIP Code

Location Description

If street location is unknown, please describe the location of the loss to the best of your ability.

Were the police called?

No

Yes

Police Report Number

Description of Loss*

Please describe what happened to the best of your ability.

Auto Claim Questions

Driver's Name*

First Last

Drivers License Number

Vehicle

(year, make, model, and/or VIN)

Where is the vehicle?

i.e. At home, auto body shop name, friend's house, side of the road, etc.

Describe damage to vehicle

Name of Other Driver*

First Last

Other Driver's Drivers License Number

Other Driver's Vehicle*

(year, make, model, and/or VIN)

Describe damage to other driver's vehicle

Description of Accident*

Please describe what happened to the best of your ability.

Workers Comp Claim Questions

Name of Injured Employee*

Date of Injury*

Time Employee Began Work

Date Employee Last Worked

Date Employer Notified*

Contact Name

(Optional) Such an union representative, office manager, significant other, etc.

Contact Phone

(Optional)

Type of Injury / Illness*

Part of Body Affected*

Equipment, Material, or Chemicals employee was using at time of injury / illness*

What activity was employee engaged in at time of injury / illness

How did the injury / illness occur?

Date Employee Returned to Work

If Fatal, Give Date of Death

Were Safeguards or Safety Equipment Provided?*

Yes

No

Were Safeguards / Safety Equipment Used?*

Yes

No

Did Injury / Illness Occur on Employer Premises?*

Yes

No

Additional Comments or Information

Upload File(s)

Optionally upload any additional files such as copies of drivers licenses, auto ID cards, estimates, forms, doctor summaries, etc.

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