ONLINE PROPERTY FORM

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

* Denotes required fields.

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Umialik Policyholder Information

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Type of Policy   Type of Policy Homeowners Inland Marine Dwelling Fire Commercial Fire

Policy Number*

Umialik Policyholder's Name

Address

City

State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Contact Name*

Contact Phone*

Person Submitting Claim is: Umialik Policyholder Umialik Agent Other Involved Party

Email of Person Submitting Claim:*

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Other Party Information

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Name of Other Party

Address

City

State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Contact

Contact Phone

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Loss Information

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Date of Loss*

Loss Location

Location of Damaged Property *

Description of Accident or Loss *

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Injury Information

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Was anyone injured?

No

Yes

If yes, how many? 0 1 2 3 4

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