Name (as listed on policy)
Street Address
City
County
State
Zip Code
Email Address
Best Telephone Number
Date of Accident or Loss (dd/mm/yyyy)
Time of Day of Accident/Loss
AM/PM? AM PM
Type of Accident/Claim Property Automobile Workers Compensation General Liability Professional Liability (E&O) Employment Practices Liability Other
Description of Accident/Loss
Name(s) of Injured Parties
Any of the following parties notified? Fire Department Police None
For Auto Claims, provide the following info: 1. Driver Name, 2. Vehicle Description, 3. Did you receive a ticket? 4. If ticketed, what was it for?
For Property Claims, is the Property habitable? Yes No
If Property is not habitable, where are you staying or planning to stay?
Additional Comments
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.
Your First Name (required)
Your Last Name (required)
Your Email (required)
Re-Enter Your Email (required)
Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
City (required)
County (required)
State (required)
Zip Code (required)
Question (required)
Phone (required)
