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Claim Department
Contacts

Lynn Rupp

Senior Vice President – Claims
201-847-2848


Lisa Rosa

Vice President – Claims
201-847-2847


Gerald Steimers

Second Vice President – Claims
201-847-2899


Rosa Avella

Claims Administrative Assistant
201-847-2863


Required Fields *

Type of Notice:
Date of Occurence *
Format MM/DD/YYYY
Date of Claim
Format MM/DD/YYYY
Time of Occurrence
Previously Reported?

CONTACT

Name *
Email
Address *
Business Phone
Residence Phone
Where to contact
When to contact

INSURED

Name *
Address *
Business Phone
Residence Phone
Where to contact
When to contact

COVERAGE

Policy Number *
Effective Dates of Coverage
From To
Agent's Name
Agent's Address
Agent's Phone

LOCATION OF OCCURRENCE - (Include City and State)

Authority Contacted
Location
Description of Accident

INJURED / PROPERTY DAMAGE

Name (Injured/Owner)
Phone No. (Include area code)
Address (Injured/Owner)
Age
Sex

Employer's Name
Phone No. (Include area code)
Address (Employer)
Description of Injury
Fatality?
Where taken?
Describe Property
(Type, Model, etc.)
Estimate $ Amount$
What was injured doing?
When can property be seen?
Where can property be seen?

WITNESSES

Second Witness Name and Address
Business Phone
Residence Phone
First Witness Name and Address
Business Phone
Residence Phone

FRAUD WARNING: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the porpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
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