Customer Service

Forms

Claims - Auto, Property, Liability

How do I report a claim?

Each insurance carrier provides 24-hour claim reporting service; instructions are enclosed in your policy. As an alternative, you may complete our online claim reporting form and we will report to the insurance carrier on your behalf.

Fill out one of the following forms to submit your Auto, Property or Liability Claim.

Select A Form
Select A Form
- Automobile Claims Report
- Property Claims Report
- Liability Claims Report
Insured's Information
Insured's Name
Group Name (If Applicable)
If part of a larger group, i.e. a Diocese, please name your sub-group, parish, etc.
Your Name
Your Phone Number
Email Address*
Address as it appears on the Registration
Street Address Address Line 2 City State ZIP Code
Accident Information
Driver's Name
Driver's Phone Number
Date of Loss
MM
DD
YYYY
Time of Accident
Location of Accident
Address
Street Address Address Line 2 City State ZIP Code
Description of Accident
Damage
Your Vehicle
Year
Make & Model
VIN Number
Plate Number
Repair shop information:
Name
Phone Number
Other Vehicle
Year
Make & Model
VIN Number
Plate Number
Other Driver's Name
Other Driver's Phone Number
Other Driver's Full Address
Street Address Address Line 2 City State ZIP Code
Damage
Carrier Name and/or Agent
Policy Number
Additional Information
Injuries
Were there any injuries? If so, please include the name(s), address and phone number of any injured parties.
Passengers/Witnesses
Were there any passengers or witnesses? If so, please include the name(s), address and phone number is possible.
Was an authority contacted?
- Yes
- No
Authority Info
If YES, please provide the accident report number and any other relevant details.
Additional Notes
Loss Information
Date of Loss
MM
DD
YYYY
Time
Location
Street Address Address Line 2 City State ZIP Code
Estimate of Damages
Description of Loss
Claimant Information
Claimant's Name
First Last
Claimant's Phone Number
Location
Street Address Address Line 2 City State ZIP Code
Description of Incident
Additional Notes
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Adding and Deleting Automobiles and Drivers

How do I add/delete a vehicle or a driver?

You may fill our one more more of the following auto change request forms to submit for processing and we will contact you in the event additional information is needed

All Auto and Driver Add or Delete Forms

Select A Form
Select a Form
- Auto Addition (New Plates)
- Auto Addition (Delete & Replace)
- Automobile Deletion
- Driver Addition
- Driver Deletion
Insured's Information
Insured's Name
Group Name (If Applicable)
If part of a larger group, i.e. a Diocese, please name your sub-group, parish, etc.
Your Name
Your Phone Number
Email Address*
Vehicle Deletion Information
Year
Make & Model
VIN Number
Termination Date
MM
DD
YYYY

Please note that if you are returning plates in either New York or Massachusetts, a copy of the plate return receipt must be submitted to our office. You may forward it by either fax or e-mail for the most prompt response, or by regular mail.
Additional Notes
Vehicle Addition Information
Year
Make & Model
VIN Number
Cost New
Passenger Capacity
Replacement Vehicle/Addition Information
Year
Make & Model
VIN Number
Cost New
Passenger Capacity
Are the plates being transferred from the old vehicle to the new one?
- Yes
- No
Registration Information
Addition Date
MM
DD
YYYY
Delete & Replace Date
MM
DD
YYYY
State in which the vehicle will be registered
Name as appears on the Registration
Address as it appears on the Registration
Street Address Address Line 2 City State ZIP Code
Effective date as it appears on Registration
MM
DD
YYYY
Principle garaging location (city & state)
Leasing/Loan Information
Leasing Company or Bank
If the vehicle is leased and/or is a loan on it, please provide the name and address of the leasing company or bank:
Additional Notes
Please include any information about after market equipment, such as whellchair lifts, plows, etc.
New Driver Information
Name
First Last
Date of Birth
MM
DD
YYYY
License Number
State of Issue
Termination Date
MM
DD
YYYY
Additional Notes
If you would like to receive a copy of this completed form, please enter a valid e-mail address.
Driver Deletion
Name
First Last
Termination Date
MM
DD
YYYY
Additional Notes
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Main: 631-423-9500
Toll Free: 800-275-9762

24 W Carver St, Huntington, NY 11743

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Toll Free: 800-275-9762

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CLIENT ACCESS

Customer Service

Forms

Claims - Auto, Property, Liability

How do I report a claim?

Select A Form

Insured's Information

Accident Information

Location of Accident

Your Vehicle

Other Vehicle

Additional Information

Loss Information

Claimant Information

Adding and Deleting Automobiles and Drivers

How do I add/delete a vehicle or a driver?

Select A Form

Insured's Information

Vehicle Deletion Information

Vehicle Addition Information

Replacement Vehicle/Addition Information

Registration Information

Leasing/Loan Information

New Driver Information

Driver Deletion

Adding and Deleting Properties

How can I add/delete or make amendments to a property?

Select A Form

Insured's Information

Addition Information

Deletion Information

If Occupancy/Type of Building is a school, please provide the following information.

Amending Limits and/or Contents of An Existing Building

Leasing/Loan Information

Building Information

Construction Type

If Occupancy/Type of Building is a school, please provide the following information.

Certificate of Insurance

I need to request a certificate of insurance. What should I do?

Insured's Information

Certificate Information

Limits being requested

Certificate Holder

What do I do if I have received a letter from my leasing company/bank asking for verification of insurance coverage?

What do I do if I received a letter from the DMV stating that they cannot verify insurance coverage?

Student Accident Insurance Form

Basic Information

If there is more than one location, please forward a list of additional locations.

If this is New Business, please provide your desired policy effective and expiration dates.

Estimated Enrollment

Number of Students and Teachers

Camp Questionnaire

Basic Information

If there is more than one location, please include a list of additional locations.