Additional Claims Document Submission - LIABILITY/PROPERTY

Fill in the information below for Submissions of Claims Documents. * must be filled out

Claims Number *

Name/Company Name *

Email Address

Phone Number

Additional Comments

Please attach any document you would like to submit below. (Maximum submission size 50MB per each file)

FRAUD WARNING:

GENERAL: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime, subject to criminal prosecution and civil penalties .

CALIFORNIA: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NEW YORK & NEW JERSEY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, shall also be subject to criminal prosecution and [NY: substantial] civil penalities.