Report a Claim Online Please use this form to expedite your personal or commercial claim reporting process. If you prefer to report your claim to one of our representatives, please call (516) 358-3500 during normal business hours. Reporter Information First Name:* Last Name:* Company: Address:* City:* State:* AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:* Phone:* Relationship to Insured: Claim Information Type of Loss:* General Liability Property Automobile Workers' Compensation Disability Date of Loss:* Time of Loss:* Insured's First Name:* Insured's Last Name:* Insured's Company Name: Insured's Address:* City:* State:* AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:* Home Phone: Business Phone: Person to Contact First Name: Last Name: Home Phone: Business Phone: Best Time to Contact: Accident/Loss Details Location of accident/loss:* Description of accident/loss:* Police/Fire Department that reported: Case Number: Injured Party Information (if applicable) First Name: Last Name: Address: City: State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: Home Phone: Age: Gender: Male   Female Occupation: Employer: Employer Address: City: State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: Damaged Property Information (if applicable) Property Owner First Name: Last Name: Address: City: State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: Property Description (please specify type, make, model, etc.): Estimate amount: Where property can be seen: Witness Information First Name: Last Name: Address: City: State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: Home Phone: Business Phone: Additional Remarks The information in this transmission shall be treated as confidential and is intended only for use by City Underwriting Agency, Inc. to service your account. Disclosure of any and all information is restricted by state and federal privacy laws and will only be used in conjunction with the rules and regulations set forth regarding "permissible use".

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	City Underwriting Agency, Inc.  |  2001 Marcus Avenue, Suite W180  |  Lake Success, NY 11042 Phone: 516-358-3500  | Toll Free: 800-762-1784  |  Fax: 516-358-3540  |  Email: info@cuagency.com