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Contact Information

Please provide us with your contact information.

First Name:
Last Name:
Street Address:
City:
State/Province
Country:
Day Phone:
Evening Phone:
Fax:
E-mail:

Information about the Loss

Name of Insured:
Date of Loss:
Type of Loss: Fire
Lightning
Flood
Theft
Hail
Wind

Other (please describe)
Police or Fire Dept to which reported:
Location of Loss:
Description of Loss:
Additional Comments:

Submit Claim

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Risk Management Services Company P.O. Box 22989 Louisville KY 40252
(502)326-5900 (800)372-5402 (502)326-5909-fax