Please complete the form below to submit claim details to ASL

Agency Information

Agency Name:

Agent Name:

Agent Phone Number:

Insured's Information

Named Insured

Address

Unit or Suite

Home Phone

Business Phone

Email Address

Zip Code:

Location:    

Contact Information

Same as above?

Contact Name

Contact Address

Unit/Suite

Contact Phone

Contact Business Phone

Contact Email Address

Zip Code:

Location:    

Location and Loss Information

Same as contact?

Loss Location Address

Loss Location Unit/Suite

Zip Code:

Location:    

Date of Loss

Time of Loss

Policy Number

Policy Eff Date

Policy Exp date

Police or Fire Dept contacted

Police or Fire Dept Report Number

Type of Loss (Please put an X in the boxes that apply)

Fire? Theft? Lightning?

Hail? Flood? Wind?

Other?

Please describe loss...

Estimated Loss Amount:

***If you are submitting a new claim and have not had a response within 24 hours, please contact us directly
at 1-800-368-2095 and ask to speak to the claims department****