Claims

Liability Claim Form

We will be happy to assist you with your liability claim. All you need to do is fill out the brief form below, then click "Submit Request" at the bottom. One of our agents will personally review your information and contact you promptly about the claim.

Entries marked with an asterisk (*) are required.

Your name:*

Insured Information

Insured's name:*
Street address:*
City:*
State:*
Zip Code:*

Loss Information

Date of loss:*	(mm/dd/yyyy)
Time of loss:*
Type(s) of loss:*	Property damage
	Bodily injury
	Premises
	Products
Location of loss:*
Description of loss:*
Authority contacted:

Claimant Information

Claimant's name:
Street address:
City:
State:
Zip Code:
Phone (include area code):
If bodily injury - description of claimant injury and where cared for:

Additional Information

Additional information being provided by insured / claimant:
	Photos
	Item list
	Estimates / Invoices
	Other (describe below)

Contact Information

Please contact me via (select one or more options):*
Phone (include area code):
FAX (include area code):
E-Mail:
Postal mail:
Street:
City:
State:
Zip:

Other

Questions, comments, or special requests:

Submit Request

NOTE:

The information you submit will be transmitted from this Web site to our staff via email through the Internet. Additionally, information you enter will be transmitted from your computer to our Web site in un-encrypted form. We believe that this transmission is unlikely to be intercepted, but we cannot guarantee privacy of the information you submit while it is passing through the Internet. If you do not wish to submit this form from the Web, please feel comfortable contacting us by telephone, FAX or other postal mail, and we will be happy to respond to you in that way.

Contact Us

FirstChoice Insurance Agency, Inc.
338 Pearl Ave.
Oshkosh, WI 54903-0766
(920) 235-3450, Toll free: (800) 368-7536, FAX: (920) 232-8731
E-Mail: mail@firstchoiceinsurance.biz