Claim Report-Home - Capital Insurance Brokers

This form will allow you to report a claim to our brokerage. You may save and continue later if necessary.

Your Information
Are you currently insured with our brokerage?
- Yes - I am a client of the brokerage
- No - I am a third party filing a claim against a client of the brokerage
Name
First Last
Primary phone number*
Secondary phone number
Email
Address*
Street Address City Province Postal Code
Your policy info
Policy number*
Insurance carrier*
Please type in the name of your insurance carrier*
Loss Information
When did the loss occur?*
YYYY dash MM dash DD
What time did the loss occur?

: Hours

Minutes

AM/PM
Please describe the incident, including WHERE it occurred and WHAT exactly happened
If you have filed a Police Report, please provide the police report number as well as the police force that the report was obtained from
Upload photos or documents
Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 2 MB, Max. files: 10.
Please upload any files you feel are relevant (pictures, police report, etc.). Maximum 10 files, up to 2MB each.

Your Information