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E-Claim Submission

We want to stress that our goal is to establish a personal relationship with all of our customers. And we also want to stress that in the event of a potential claim we want our customers to call our office immediately, however we are also about giving our customers options. Below is a brief form to report the basic information associated with your potential claim. Please fill out the information with as much detail as possible and someone in our office will be in touch with you as soon as possible to assist you with your claim.

Disclaimer notice:

Please note this form does not constitute a formal claim submission to your insurance carrier… this is simply another means to which you can notify our office in the event of a potential claim.

I have read and understand the disclaimer notice (must check before e-form can be submitted)

 


* Please note that all fields are required.

First Name:

Last Name:
Business Name:
Policy Number:

(please type "unknown" if you do not know your policy number)

Preferred Phone #:
E-Mail Address:
Best time to call:

A.M.

P.M.

Coverage Type:  
Details of Incident:  

   

 
     
 
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  Life and Health Insurance 
  Bond Department 
 
     
 


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107 North Main Street, PO Box 885  - Columbiana, Alabama - 35051
Phone (205) 669-3158 - Toll Free (800) 493-7420 - Fax (205) 669-3209