West Virginia Insurance | Allegheny Insurance

General Liability Loss Claim Form
Complete and submit the form below to make a claim on your auto insurance. Once submitted, the form will be e-mailed to our staff, and you will be contacted for confirmation.

GENERAL INFORMATION
Name:
Address:
City, State, Zip:
Daytime Phone #:
FAX #:
Evening Phone #:
E-Mail:
How would you like to be contacted?:		Daytime Phone Evening Phone E-mail FAX Mail
LOSS INFORMATION
Date of Loss):
Location:
Description of Loss:
Police or Fire Contacted:		Yes No
Description of Injured Person
Name:
Address:
City, State, Zip:
Daytime Phone #:
FAX #:
Evening Phone #:
Hospital or Medical Treatment Provided?:		Yes No
Where?:
Description of Property Damaged
Estimated Cost of Damage:
Property Location:
1st Witness Name:
1st Witness Number:
2nd Witness Name:
2nd Witness Number:
3rd Witness Name:
3rd Witness Number:

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At Allegheny Insurance we consider our strength to be the personal service provided by our skilled and knowledgeable staff. Every member of our team works hard to ensure a personal and exceptional level of service with each client interaction.This is the Allegheny Difference. We encourage you to Meet our staff.