Other REPORT A PERSONAL 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 #2: City:(required) State:(required) Zip Code:(required) Policy Number: Contact Name:(required) Contact Phone:(required) Contact Email:(required) Location of Loss:(required) Description of Loss:(required) Has this loss been reported to the Police Department or Fire Department?(required) Yes No 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.