File A Claim - Nemitz Agency Insurance Services

When the unexpected happens, we’ll work with you to provide fast resolution and help get you back to good. Please enter as much information as you can in the fields below and attach pictures if possible in order to help us submit your claim.

A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

* Required field. Please fill out as much information as you are able. Incomplete information will require a phone call to obtain the information needed to complete your claim.

TYPE OF CLAIM

Auto Property Liability

NAME OF INSURED

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE

WHEN TO CALL

EMAIL ADDRESS

DATE OF LOSS

DESCRIPTION OF LOSS EVENT

POLICE OR FIRE DEPARTMENT CONTACTED?

Yes No

NAME OF DEPARTMENT

OTHER PARTY INVOLVED

NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE

ALTERNATE PHONE

IF ADDITIONAL PARTIES INVOLVED, PLEASE ADD HERE WITH NAME, ADDRESS, PHONE

OTHER PROPERTY INVOLVED

DESCRIBE OTHER PROPERTY INVOLVED (PROPERTY TYPE, VEHICLE YEAR, MAKE, MODEL, ETC.)

WITNESSES

WERE THERE WITNESSES

Yes No

If yes, please answer the following:

NAME OF WITNESS

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE

ALTERNATE PHONE

PHOTOS

You can also email photos to info@nemitzagency.com.