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.
Comments
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Policy Holder Information

Loss Information

Additional Information

Insured/Property Damaged

Witnesses

Witness 2 Details

Claim Submission