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 * Client Address  * required * Client City/State/Zip  * required * Client Telephone Number  * required * Client Fax Number  * required   Client Email Address   Claim Number   Policy Number   Date of Loss * Insured Name  * required   Insured Address   Insured City/State/Zip * Insured 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   Claimant Address   Claimant City/State/Zip   Claimant Telephone   Description of Loss   Special Instructions/Services Required