Worthington Leavitt - Submit Claim

Submit a Claim

Name of Contact: *	Name of Insured:
Contact Telephone: *	Contact Email:
Date of Claim:	Time of Claim:
Location of Claim:	Insurance Company:
Insurance Type:	Type of Claim:

Brief Description of Claim:

Other People Involved and their Contact Information:

List Authorities that were Called:

Any Other Pertinent Comments:

After submitting this form, we will contact you as soon as possible.

Please note this is an alternative method for communicating with us. If you have any questions or need immediate help with your claim please give us a call.