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Earthquake Property Loss Claim Form


Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Alternate Phone Number
E-Mail Address *
Policy Number *
Loss Overview
Loss Type *
What date did the incident take place? *
/ /
How severe was the damage? *
Describe the Loss *
Submission Validation

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  Requested changes to your policies that remove or reduce coverage will require a signature from the insured.  Your agent will contact you to secure your signature. If you have any questions, please feel free to contact us.


Affiliated with Lord and Associates Insurance Agency, Inc.