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Online Incident Reporting Form

IMPORTANT NOTICE: It is your contractual responsibility to report any Claim, Loss or lawsuit, or any incident or event which could reasonably lead to a Claim, Loss or lawsuit, directly to us as set forth in the Policy. If for any reason you are unable to use our Online Claims App for this purpose, it is still your responsibility to report any such Claim, Loss, lawsuit, incident or event to us as set forth in the Policy by another method such as by facsimile at 1-877-452-6909, or by telephone at (801) 304-5500 or 1-800-257-5590. Your failure to do so may jeopardize any coverage as set forth in the Policy.

Please complete the form below. Fields marked with an asterisk are required (*).

  • Date Format: MM slash DD slash YYYY
  • Name Email PhoneActions
       
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  • If you would like to submit photos with this claim, please add them below. Photos should have the "jpg" extension. Up to five (5) images can be attached to this claim.
    Drop files here or
    Accepted file types: jpg.