Online Claim Form

Online Claim Form:

"*" indicates required fields

First Notice of Loss

Please fill out all of the information that you have available at this time. We will reach out to you to verify the information and start the claims process.

Carrier Name*

Policy Number*

Policy Start Date

Date

Policy End Date

Date

Date of Loss*

Date

If your date of loss is outside of policy period, please do not continue with this form. Reach out to your insurance agent for further direction. If further assistance is needed please reach out to Coterie Policy Support @ 855-566-1011.

Insured Info

Insured Company Name

Insured Company Address

Street Address Address Line 2 City State ZIP Code

Insured Contact Name

First Name Last Name

Insured Contact Phone Number

Please enter a valid phone number

Insured Contact Email

example@example.com

Is the loss location different than the above?*

Yes

Choose a Loss Coverage Type*

Witness Info

Was there a witness?*

Yes

Acknowledgment

Name of Individual Reporting Claim*

First Name Last Name

Your Relationship to the Claim*

Your Phone Number*

Please enter a valid phone number.

Your Email*

example@example.com