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CLAIM FORM

Claim Form

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
 Fax:  

Date of Loss:  

Time of Loss:  
Location of Incident/Loss:  
Description of Incident/Loss:  
Were the authorities called:  
Additional Information that might help expedite the claim process:
By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim. Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.


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QUOTE CENTER

PROGRAMS
Our programs include:
  • Fast Food Franchises such as KFC, Burger King, Jack in the Box and more (over 300 locations)
  • Franchise Service-Gas stations, car washes and convenience stores
  • California Counsel for Parent Participation Nursery Schools
  • Non-Profit Insurance Alliance & Nonprofits United programs
  • Taxicab, Para-transit and Limousine Specialty program
  • Attorney & Accountants Safety Association

CUSTOMER CARE CENTER
5 Corporate Park, Suite 170, Irvine, California 92606 , Phone: 800-854-7234 , Fax: 949 419-0491  |  Email Us
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