GHM Insurance Agency

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of Insurance

Report a Claim Form

Your Name:

Your email address:

Street Address:

City:

State:

Zip Code:

What is the phone number where you can be reached?:
Additional number:
What is the best day to reach you?
What is the best time to reach you?

What type of claim are you reporting?

if Other, please describe...

What was the date of the claim?:

What was the time of the claim?:

Where did the claim occure ie. location of accident, property address, etc.?

Please describe the claim to us:

If this is an auto claim, please answer the following questions:

Which vehicle was involved in the claim?
Who was driving your vehicle?
What is the address of the other party?
What is the phone number of the other party?
What is the name of the agent/insurance carrier of the other party?

If there were injuries, please provide us with the names and addresses of the injured person(s).

Names, addresse, and phone number of any witnesses to the accident?

Any other information we should know about the claim?

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Disclaimer: Please be advised that no insurance can be purchased, bound, or put into effect over the GHM Agency website. To start a policy or make changes to an existing policy, you must first speak with a GHM agent who will assist you accordingly. Thank You.