Newberry Insurance Agency, Inc.

1760 Ellington Rd.
South Windsor, CT 016074

Phone: 860-644-3049     Fax: 860-644-7789

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.

Homeowners Accident Claim Form

We provide insurance coverage in Massachusetts only. Sorry, other states not available.

Full Name:
Address: City:
Mail Address (if different): State: Zip:
Email: Home Phone: (with area code)
Office Phone: (with area code)
Ext: 		Fax: (with area code)
Best time to contact:

About the loss

  1. Date loss occurred (DD/MM/YY)

    //

  2. Location the loss occurred

    City:

    Street:

  3. Did the police or fire department(s) respond to the loss?

    Yes No

    If yes, what police and/or fire department(s)? (town)

  4. What kind of loss did you experience?

    Wind

    Water

    Fire

    Theft

    Other

    If other, please list:

  5. Is the property habitable?

    Yes No

    If no, where can you be reached?

  6. Please describe the problem or incident

    7. Personal Injury

  7. Who was injured?

    Full Name:

    Address:

    City: State: Zip:

    Phone:

  8. Describe the injuries sustained

  9. Questions and/or Comments

Important Note: If possible please fax a copy of the police report to Newberry Insurance Agency, Inc.860-644-7789