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Page 1

Report A Claim

Use this form to provide us with detailed loss information which will expedite the claim handling process. Supporting files such as photos or documentation can be attached at the bottom of the form. You may also save your work in progress before submittal.

Your online claim will be processed during normal business hours Monday - Friday 8am to 4:30pm. During a catastrophic weather event such as a hurricane, we will extend our online processing hours to assist you with your storm claim.

Emergency Claims

- During business hours, contact your Cadence Insurance representative

- After-hours, call our Emergency Line at 877-897-9312

Please note, employee injuries must be reported directly to your workers' compensation insurance carrier.

Who is reporting this claim?

Cadence Insurance Agent

Agent's Phone Number

Policy Holder Information

First Name

Last Name

Company Name

Location/Branch/Store

Street Address

City

State

Zip

Phone

Cell

Your Insurance Company

Your Insurance Policy Number

In what state is your agent's office located?

Page 2

Claim Details

Date of Incident

Time

00:00 am, 00:00 pm

Address or Location of Incident

City

State

Zip

Responding Police Department

Case Number

Page 3

What type of claim are you reporting?

Describe Incident

Was property damaged?

Cause of loss

Describe other kind of loss

Your Vehicle

Year

Make

Model

VIN

License Plate

State

Describe Damage to your Vehicle

Was your vehicle towed?

Towing Company Name

Towing Company Phone

Your Driver

First Name

Last Name

Phone

Cell

Number of Passengers

Describe the Property That Was Damaged

Property Owner

First Name

Last Name

Street Address

City

State

Zip

Phone

Describe Damage

Is the property habitable?

Was the fire department involved?

Responding Fire Department

Case Number

Was another vehicle involved?

Is other driver's information available?

Other Driver Information

First Name

Last Name

Street Address

City

Zip

Phone

Cell

Insurance Company Name

Policy Number

Other Vehicle Information

Year

Make

Model

VIN Number

License Plate

State

Damage to Other Vehicle

Number of Passengers

Was their vehicle towed?

Was anyone injured?

Injured

First Name

Last Name

Street Address

City

State

Zip

Phone

Cell

Sex

Was 911 called

Was injured transported to a hospital?

Hospital Name

Describe Injury

Was there a Witness

Witness

First Name

Last Name

Street Address

City

State

Zip

Phone

Page 4

Additional Comments

I would like to upload an optional file(s). Otherwise, click "Submit."

You can upload any additional files here

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