Other REPORT A BUSINESS CLAIM For all other carriers, please complete the form below: Please enter the insured’s personal information so we can look up your policy and contact you regarding your claim. Name of Insured:(required) Mailing Address Line #1:(required) Mailing Address Line #2: City:(required) State:(required) Zip Code:(required) Policy Number: Contact Name:(required) Contact Phone:(required) Contact Email:(required) How should we contact you? Email Phone Describe Your Claim: Terms: This claim cannot be considered filed under the notification guidelines of your policy unless you receive a reply from our firm. If you haven’t received a reply within 48 hours, please contact us via phone. If you have any additional paperwork, please fax to Robin Roberts 706-883-8915 after submitting this form.