SWI Claims Personal Lines Loss Notice

Policy Holder Information
Fields marked with a red star (*) are required.
Name*
First Last
Policy Number*
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Primary Phone Type*
Secondary Phone
Secondary Phone Type
Loss Information
Date Loss Occurred*
Date Format: MM slash DD slash YYYY
Time Loss Occurred*

: HH

MM
Type of Loss*
Loss Location #
Loss Type if Other
Loss Reported To*
Report Number
Where Did The Loss Occur*
Address Where Loss Occurred (If Different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Information
Upload a File
Drop files here or

Accepted file types: jpg, gif, png, pdf, tiff.
Upload up to 5 photos with your claim by clicking the "browse" button and locating photos on your device.
Tell Us Who To Contact Regarding This Claim*
When Is the Best Time to Contact This Person?*
Other Contact Details*
First Last
Other Contact Phone*
Who is Submitting the Claim?*
Submitter Email*
First & Last name (if other)*
Name of Agency (if applicable)
Claim Submission
PLEASE NOTE: You must click CONTINUE below to review your information and then submit before your claim is processed.
Name
This field is for validation purposes and should be left unchanged.

Policy Holder Information