SWI Claims General Liability Loss Notice

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

: HH

MM
- Check If Unknown
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
Description of loss
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?*

: HH

MM
Who Is Submitting This Claim?*
Insured/Property Damaged
First & Last Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone*
Witnesses
Unknown
- Check If Unknown
Witness #1 Name
First Last
Witness #1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Witness #1 Phone
Witness 2 Details
Witness #2 Name
First Last
Witness #2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Witness #2 Phone
Claim Submission
PLEASE NOTE: You must click CONTINUE below to review your information and then submit before your claim is processed.
Email
This field is for validation purposes and should be left unchanged.

Policy Holder Information

Loss Information

Additional Information

Insured/Property Damaged

Witnesses

Witness 2 Details

Claim Submission