Online Claims Submission Form

To report a claim online please complete the fields below. You will receive email confirmation, and you will be contacted by our claims staff during business hours.

Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance containing a false statement as to any material fact may be guilty of insurance fraud.

Your Information

Your Name:*

E-mail Address:*

Street Address: City, State, Zip:

Primary Phone:*

Secondary Phone:

Policy Information

Policyholder Name:

Policy Number:

Member Number:

Claim Information

Claim Type:

Date of Loss:

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Loss/Incident Location:

PMC Insured Vehicle: (if applicable) Year

Make

Model

Additional Information

Comments:

Report a Claim

Your Information

Policy Information

Claim Information

Additional Information