Electronic Claim Submission Form
Please complete the form below to submit your claim. If you prefer, you can fax your assignment to (309)694-9022. Thank you. The fields marked with (*) are required fields. * Company Name  * required * Claims Contact/Adjuster  * required * Address  * required * City/State/Zip  * required * Telephone Number  * required * Fax Number  * required   Email Address   Claim Number   Policy Number   Date of Loss * Insured Name  * required   Address   City/State/Zip * Telephone Number  * required   Type of Loss Property General Liability Liquor Liability Auto Liability Auto Appraisal Heavy Equipment Appraisal Worker's Compensation Scene Investigation Police Report Other   Coverage Information Replacement Cost Actual Cash Value Collision Comprehensive Other (Comment in Special Instructions)   Applicable Policy Limit   Deductible (if any)   Claimant Name   Address   City/State/Zip   Telephone   Description of Loss   Special Instructions/Services Required