Striker

REPORT A CLAIM

Striker

If you have ANY information regarding a potential claim, please go ahead and report whatever information you have (even if it is incomplete). The sooner claims are reported, the quicker ACG can start the investigation.

Customer Information

Client Name

First Last

Program Code:

Policy #:

Time of Loss Event

Date of Loss Event

Date Reported

Insured Information

Insured Contact

First Last

Insured Address

Street Address Address Line 2 City State ZIP Code

Business Phone

Other Phone

Best Hours To Contact

Description of Loss

Please describe:

Witness Name

First Last

Witness Address

Street Address Address Line 2 City State ZIP Code

Phone

Witness Name (2)

First Last

Witness Address (2)

Street Address Address Line 2 City State ZIP Code

Witness Phone (2)

Witness Name (3)

First Last

Witness Address (3)

Street Address Address Line 2 City State ZIP Code

Witness Phone (3)

Description of Auto(s)/Equipment Involved

Unit 1 (Insured)

Unit 2

Unit 3

Upload additional Auto(s)/Equipment

Max. file size: 96 MB.

Description of Reported Injuries

Injured Party 1

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone (If available)

Injured Party 2

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (If available)

Additional Enclosures

Please upload names, addresses, and phone numbers for any other witnesses, relevant drivers, and/or additional injured parties.

Max. file size: 96 MB.

Emergency Services on Scene

Yes

Party Transported

Hospital Information

Phone

Person Reporting Loss

Relationship to insured

Title

Business Phone

Other Phone

Preferred Contact Method

Best Hours to Contact

Date

Please upload any additional information you have (i.e. police report, vehicle estimates, photos, contracts, etc.)

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.

If you have any issues with submitting this claim form, please contact us at 1-800-597-7790 or e-mail us at newlossreporting@appliedclaims.com

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