Report A Loss

To report a loss, please fill out this form. We will respond as soon as possible between the hours of 8:30am and 4:30pm. To submit a claim during other hours, please call (860) 590-7717.

Policy Holder

First Name*
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Last Name*
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Email*
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Address*
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City/State*
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Home Phone
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Cell Phone*
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Business Phone*
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Insurance Company

Insurance Company Name
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Contact Phone
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Contact Email*
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Broker/Agent

Broker/Agent Name
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Broker Phone
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Broker Email*
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Loss

Date of Loss
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Loss Type
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Loss Description
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Special Instructions

*required field