715-228-5541
N1211 County Road B, Coloma, Wisconsin 54930
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Fields with (*) are required.
*
Type of Claim:
Property
Auto
Liability
*
Policy Number:
*
Date of Loss:
*
Person Reporting the Claim:
*
Insured:
*
Contact Phone Number (at least one required):
Home Phone Number:
Work Phone Number:
Cell Phone Number:
*
Best Time to Call:
*
Loss Location:
*
Driver Name:
*
Vehicle Involved (Year, Make & Model):
Claimant Name:
Claimant Phone Number:
*
Loss Description:
*
Verification:
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