Regional Claims Management Group, LLC

Submit Claims

Please fill in the following information and click on Submit at the bottom to submit your claim.

Your claim will be submitted to our office and you will be contacted shortly.

Submitted By Contact Information

First Name:
Last Name:
Phone:
Fax:
Email:
Company Information
Company Name:
First Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip:
Contact Phone:
Contact Fax:
Contact Email:
Policy Information
Policy Number:
Policy Effective Date:
Loss Information
Date of Loss:
Customer Claim Number:
Location of Loss:
Brief Description of Loss:
Insured Information
Insured Person or Company:
Contact First Name:
Contact Last Name:
Insured Address:
Insured Address 2:
City:
State:
Zip:
Insured Home Phone:
Insured Work Phone:
Claimant Information
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address 2:
City:
State:
Zip:
Claimant Home Phone:
Claimant Work Phone:
Special Instructions:
Method of Confirmation:
Please click the Submit button only once