Online Property Claim Form

REPORT A PROPERTY CLAIM
UMIALIK INSURANCE COMPANY
a member of the WESTERN NATIONAL INSURANCE GROUP

* Denotes required fields.

Umialik Policyholder Information

Type of Policy

Policy Number*

Umialik Policyholder's Name

Address

City

State

Zip

Contact Name*

Contact Phone*

Person Submitting Claim is:

E-mail of Person Submitting Claim:*

Name of Other Party

Address

City

State

Zip

Contact

Contact Phone

Date of Loss*

Loss Location

Location of Damaged Property *

Description of Accident or Loss *

Was anyone injured?

Yes

If yes, how many?

Name of First Injured Party

Description of Injury

Telephone Number

Name of Second Injured Party

Description of Injury

Telephone Number

Name of Third Injured Party

Description of Injury

Telephone Number

Name of Fourth Injured Party

Description of Injury

Telephone Number

If more than 4 injuries, please list below