Report A Claim – Apex Insurance Agency Ltd

Report A Claim

IF YOU HAVE INCURRED A LOSS YOU CAN NOTIFY US ONLINE. YOUR ACCIDENT OR LOSS MUST BE REPORTED WITHIN THE STIPULATED TIME STATED ON YOUR POLICY.

Claim Report

Policy Number

Apex Insured Name (If a Company)

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Occupation

Contact Number

Email

Date of Birth

Incident Date & Time

Address/Location of Incident

Address Line 1

Address Line 2

City

State

Zip Code

Country

Are you the sole owner of the property for which he claim is being made?

How did the incident occur?

Were the police or respective authorities verified?

Yes

No

If yes, provide the police station address and the officer's name and badge number.

Please provide the witness(es) name

Please provide the witness(es) address

Please provide the witness(es) contact number