LeMars Insurance Company - Customer Service - Policyholder Claim Form

Customer Service - Policyholder Claim Form

If your loss involves an emergency situation, please immediately call our 24-Hour Claim Reporting Service at 1-800-545-6480.

Policyholder Information

* First Name:
* Last Name:
* Street Address:
* City:
* State: * Zip Code:
Home Phone:
Work Phone: Ext:
Cell Phone:
* Best Way to Contact:

* Indicates a required field. Auto Year, Auto Make, Auto Model are only required if Auto is selected Claim Type.

Claim Information

* Policy Number:
* Claim Type:
* Auto Year:
* Auto Make:
* Auto Model:
* Date of Loss (MM/DD/YYYY):
* Brief Description / Comments: