ZOLOFRA INSURANCE AGENCY

Ready to protect you today for what matters tomorrow.

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Notice of Claim or Loss

*Name (as listed on policy) *Email Address *Best Telephone Number *Date of Accident or Loss (dd/mm/yyyy) Time of Day of Accident/Loss AM/PM?
AM
PM
*Type of Accident/Claim
Property
Automobile
Workers Compensation
General Liability
Professional Liability (E&O)
Employment Practices Liability
Other
*Description of Accident/Loss
*Name(s) of Injured Parties
*Any of the following parties notified?
Fire Department
Police
None
For Auto Claims, provide the following info: 1. Driver Name, 2. Vehicle Description, 3. Did you receive a ticket? 4. If ticketed, what was it for?
For Property Claims, is the Property habitable?
Yes
No
If Property is not habitable, where are you staying or planning to stay? Additional Comments

* indicates a required field.

Please utilize the "Submit" Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not "Refresh" the page because all data entered onto the form will be lost.

Š2010