General Loss Claim - Amynta Group

Use this form to initiate a general loss claim. We understand that not all the information will be immediately available, please provide as much detail as possible.

Guardsman Claims - General Loss Claim

Date
MM slash DD slash YYYY
Name of Agency*
Reported By*
First Last
Phone
Email
Insured Business Name
Address
Street Address City State ZIP Code
Phone
Fax
Email
Date Of Loss
MM slash DD slash YYYY
Time Of Loss

: Hours

Minutes

AM/PM
Insurance Carrier
Policy Number
Insured
Insured's Mailing Address
Street Address City State ZIP Code
Phone
Email
Contact
Name Of Contact
First Last
Phone
Email
When To Contact
Occurrence
Location Of Occurrence (if different than insured's address)
Street Address City State ZIP Code
Police Or Fire Department Contacted
- Yes
- No
Report Number
Describe Location Of Loss If Not At Specific Street Address
Description Of Occurrence
Type Of Liability
Premises: Insured Is
- Owner
- Tenant
Owner's Name (if different than insured)
First Last
Address (if different than insured)
Street Address City State ZIP Code
Claimant's Information
Name
First Last
Address
Street Address City State ZIP Code
Phone
Email
Occupation
Describe Injury
What Was Injured Doing
Witness
Name
First Last
Address
Street Address City State ZIP Code
Phone
Email
Remarks
Consent*
I have read the Fraud Warning Notice
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Guardsman Claims - General Loss Claim

Insured

Contact

Occurrence

Type Of Liability

Claimant's Information

Witness