Submit a Claim

Contact our Claims team at (800) 666-5692 with any questions.

For Lloyds of London policies, please complete the ACORD Property Loss Notice, ACORD Liability Notice, and/or ACORD Auto Loss form(s) and email to claims@jmwilson.com.

Agent First Name: *

Agent Last Name: *

Agent Email: *

Agency: *

Agency Code:

Policy Number: *

Insured Person's Information:

Insured Name: *

Insured Primary Phone: *

Insured Mailing Address: *

City: *

State: *

ZIP: *

Contact Name: *

Contact Primary Phone: *

Date of Loss: *

Loss Type(s):

Property Loss

Automobile Loss

General Liability Loss

Property Loss:

Location of Loss: *

Police Report Number (if applicable):

Kind of Loss: *

Description of Loss and Damage: *

Description of Injury/Damage:

Automobile Loss:

Location of Loss: *

Police Report Number (if applicable):

Description of Accident: *

Insured Vehicle:

Year: *

Make: *

Model: *

Body Type: *

VIN: *

Owner's Name *:

Owner's Address:

City:

State: *

ZIP:

Driver's Name:

Driver Phone:

Driver's Address:

City:

State: *

ZIP:

Describe Damage:

Where Vehicle Can Be Seen:

Other Vehicle / Property Damaged

Year:

Make:

Model:

Body Type:

VIN:

Owner's Name:

Owner Phone:

Owner's Address:

City:

State: *

ZIP:

Describe Injury/Damage:

General Liability Notice of Occurrence / Claim

Location of Loss: *

Police Report Number (if applicable):

Description of Accident: *

Injured Party's Name:

Injured Party's Phone:

Injured Party's Address:

City:

State: *

ZIP:

Age:

Sex:

Occupation:

Describe Injury/Damage:

Remarks:

Submit a Claim Supporting Files:

Attachment:

Select File: Only PDFs, images (JPG and PNG), and Microsoft Word files under 30.00MB are accepted.

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