Garage

REPORT A CLAIM

Garage

Reporting Party Information

Reporting Party Name(Required)

First Last

Reporting Party Phone Number(Required)

Loss Detail Information

Date of Loss

Time Of Loss

Loss Type

Location of Loss

Street Address Address Line 2 City State ZIP Code

Description of Loss

Insured Detail Information

Policy Number

Insured Name

Address

Street Address Address Line 2 City State ZIP Code

Contact Phone(Required)

Contact Email(Required)

Contact Name(Required)

Agent Detail Information

Agency Name

Contact Name

Agent Email

Agency Phone Number

Agency Contact Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Drivers

Insured Driver

Insured Driver Address

Street Address Address Line 2 City State ZIP Code

Insured Vehicle VIN

Insured Vehicle Description

Claimant Driver

First Last

Claimant Driver Address

Street Address Address Line 2 City State ZIP Code

Claimant Vehicle

Claimant Vehicle VIN

Claimant Vehicle Description

Upload Documents: If you need to upload more than a single attachment, please upload them as a single zip file.

Max. file size: 512 MB.

If your file is more than 512 MB, please contact your assigned claim adjuster for further instructions.

Please answer the security question: 4 + 7=?

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Address

15301 Dallas Parkway, Ste 500
Addison, TX 75001

Phone

Toll Free: 800-597-7790
Fax: 800-337-8131

Email

info@appliedclaims.com
newlossreporting@appliedclaims.com

Fraud Reporting

Fraud Hotline: 800-342-3504
fraudreporting
@appliedclaims.com