Please complete the following form to begin the claim process. Once you have completed the form, you will be given the chance to verify the information you have provided. Policy NumberPlease provide your policy number, if you know it.Your Name*Your Email* Home / Cell Phone*Office / Work PhoneBest Time to Call*SelectMorningAfternoonEveningASAP Address of the Property* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Loss* MM slash DD slash YYYY Please Describe the Loss*Any additional info on damages? Do you have photos of the damage?* Yes No How many photos?*12345 Photo 1 Photo 2 Photo 3 Photo 4 Photo 5 Consent* I certify the data I have entered is truthfulI agree to receive communications by text message from West Side Mutual Insurance Association about my inquiry/service request. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy link at the bottom of this page to learn how your data is used. I agree to the phone SMS privacy policyI agree to receive communications by text message from West Side Mutual Insurance Association about my inquiry/service request. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy link at the bottom of this page to learn how your data is used. Δ
