Online Incident Reporting Form

Claims Direct Access is comprised of highly skilled attorneys and specialists who will ensure you receive frequent communication, professional advice, and professional representation throughout the entire process.

How To Submit A Claim

There are 2 ways you can submit a claim with CDA:

  1. Complete and submit the incident reporting form.
    • Fill out the online form below and click “submit” at the bottom to submit a claim.
    • As an alternative to the online form, you can print/download this PDF version. When filled out, please send to info@claimsdirectaccess.com.
  2. Contact us.
    • Call 877-585-2849 to submit a claim.
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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 CDA App to submit a claim or unable to fill out the form below 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 telephone at 1-877-585-2849, by email at info@claimsdirectaccess.com, or by facsimile (Toll-Free) at 1-877-452-6909. Your failure to do so may jeopardize any coverage as set forth in the policy.

Personal Information:

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

MM slash DD slash YYYY

Policy Information:

Are You the Policyholder?
MM slash DD slash YYYY

Witness Information:

Click on the button below to get started.
Witness First Name Witness Last Name Witness Email Witness Phone NumberActions
    
There are no Witnesses.

Maximum number of witnesses reached.

Photos:

If you would like to submit photos with this claim, please add them below. Up to five (5) images can be attached to this claim. Accepted file types: jpg, png, pdf, tiff, bmp, heic. Max file size: 20 MB

Drop files here or
Accepted file types: jpg, png, pdf, tiff, bmp, heic, Max. file size: 20 MB, Max. files: 5.