Report a Claim

General Information

Not for RLI Workers’ Compensation Claims – Please call 877-863-5096.

Agency/Producer Number

What is your name?

First Name

Last Name

What is your relationship to the insured?

Agent Attorney Claimant Insured/Principal

Other:

Are you the primary contact for this claim?

Yes No, I'm filling this out on behalf of someone else

Name of Primary Contact

First Name

Last Name

Company Name of Contact

Phone Number of Contact*

Email of Contact*

Policy or Bond Number*

Enter policy # or "unknown"

Do you know the date of loss?

No Yes

Date of Loss*

Time of Loss

:

Is this an auto claim?

No Yes

Description of Claim

If you are providing details in an attachment, type “see attached” in the field below to continue. Please do not forget to upload any attachment(s).

Describe the incident*

Claim Documentation

Upload claim documents

No File Chosen

File uploads may not work on some mobile devices.

Large files (< 10 MB) may result in longer upload times

Location of Claim

Address of claim

Address Line 1

Address Line 2

City

State

ZIP Code

Claimant Information

You are able to add up to four claimants.

Claimant name

Phone

Email

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add another claimant?

No Yes

Claimant 2

Claimant name

Phone

Email

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add another claimant?

No Yes

Claimant 3

Claimant name

Phone

Email

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add another claimant?

No Yes

Claimant 4

Claimant name

Phone

Email

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Vehicle Information

You are able to add up to four vehicles.

Year

Make

Model

VIN

Would you like to add another vehicle?

No Yes

Vehicle 2

Year

Make

Model

VIN

Would you like to add another vehicle?

No Yes

Vehicle 3

Year

Make

Model

VIN

Would you like to add another vehicle?

No Yes

Vehicle 4

Year

Make

Model

VIN

Additional Comments

Any additional comments