FORMS

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Claims Form

Names of Insured Please enter your full name

Address of Insured Please enter your full address

Policy Number (if available) If you have one, please enter your policy number

Type of Insurance Please select your type of insurance

Claim to Policy Type Please select the type of policy for your claim

Date of Loss and/or Injury Please enter the date of your loss/injury

Time of Loss and/or Injury Please enter the time of your loss/injury

Location of Loss and/or Injury Please enter the location of your loss/injury

Description of Loss and/or Injury Please enter the description of your loss/injury

If Auto Claim (Personal or Business)

Year of your Vehicle Please enter the year of your vehicle

Make of your Vehicle Please enter the make of your vehicle

V.I.N. of your Vehicle Please enter the V.I.N. of your Vehicle

Driver of your Vehicle Please enter the name of the driver of your vehicle

Driver's Date of Birth Please enter the driver's date of birth

Driver's License Number Please enter the driver' s license number

Driver's Address and Phone Number Please enter the driver's address and phone number

Info on Other Vehicles Involved Please enter information on other vehicles involved

Injuries to Vehicles - Your Vehicle or other Vehicles Please indicate if there were damages produced to vehicles

If Yes, Describe Injuries Please describe damages suffered by vehicles

If Workers Compensation Claim

Name of Injured Employee Please enter complete name of injured employee

Address of Injured Employee Please enter complete address of injured employee

Phone Number of Injured Employee Please enter phone number of injured employee

SS Number of Injured Employee (claims are tracked by employees' SS #) Please enter SS number of injured employee

Your Contact Info

Home Phone Number Please enter your home phone number

Best Time to Contact You at this Numbre Please enter the best time to contact you at this number

Cell Phone Number Please enter your cell phone number

Best Time to Contact You at this Number Please enter the best time to contact you at this number

Work Phone Number Please enter your work phone number

Best Time to Contact You at this Number Please enter the best time to contact you at this number

Please enter your name:

Please enter your email address:

Serving the following towns of the Northshore and Southshore of Long Island:

Nassau County -Baldwin, Garden City, Levittown, Valley Stream, Manhasset, New Hyde Park, Port Washington, Cold Spring Harbor, Glen Cove, Great Neck, Lloyd Harbor, Muttontown, Hicksville, Oyster Bay, Old Brookville, Roslyn, Massapequa, Wantagh, Bethpage, Seaford, Syosset, Woodbury and the surrounding areas.

Suffolk County - Babylon, Lindenhurst, Bayshore, Bohemia, Hauppauge, Melville, Shirley, Mastic, West Islip, East Islip, Oakdale, Sayville, Bayport, Huntington, Northport, Stonybrook, Kings Point, Smithtown, Saint James, Port Jefferson, Setauket, Mount Sinai, Miller Place, Center Moriches, Selden, Holbrook, Ronkonkoma, Medford and the surrounding areas.

Also serving the Five Boroughs and Tri State Area.

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