Information pertaining to the event

Kind of event (disaster) * Please select Disaster Fallen materials Water Fire Smoke Vehicle impact Water infiltration Snow load Sewage backup Vandalism Wind Break-in Other

Address of occurrence *

City *

Emergency repairs are necessary.

Information on the insured party

Given and last name *

Telephone *

Insurance policy nb. *

File / claim number *

Insurance company *

Underwriter surveyor

Information about you

Given and last name *

Your identification * Please select Insurance company Independent insurance adjuster Insurance broker GUS franchisee GUS employee Private Fireman Other

Company

Telephone *

Email *

Comments / remarks

How did you hear about us?

Please select Word of mouth Search engines Other