Prime Insurance Company Claims | Incident Reporting Form

IMPORTANT NOTICE!

It is your contractual responsibility to report any claim, loss or lawsuit, or any incident or event which could reasonably lead to a claim, loss or lawsuit, directly to us as set forth in the policy. If for any reason you are unable to use our Online Claims App for this purpose, it is still your responsibility to report any such claim, loss, lawsuit, incident, or event to us as set forth in the policy by another method such as by telephone at 1-800-257-5590 or by facsimile at 1-877-452-6909. Your failure to do so may jeopardize any coverage as set forth in the policy.

Online Incident Reporting Form

Please complete the form below. Fields marked with an asterisk are required (*).

Today's Date*
MM slash DD slash YYYY
YOUR NAME*
YOUR ADDRESS
CITY*
STATE*
ZIP CODE*
Your Email*
YOUR PHONE*
POLICY HOLDER NAME*
POLICY HOLDER ADDRESS
POLICY HOLDER CITY*
POLICY HOLDER STATE*
POLICY HOLDER ZIP CODE*
POLICY NUMBER*
DATE OF INCIDENT*
DESCRIPTION*

Witness Information

Name	Email	Phone	Actions

There are no Witnesses.

Photos
If you would like to submit photos with this claim, please add them below. Photos should have the "jpg" extension. Up to five (5) images can be attached to this claim.
Drop files here or

Accepted file types: jpg, png, pdf, tiff, bmp, heic, Max. file size: 25 MB, Max. files: 5.
Name
This field is for validation purposes and should be left unchanged.

*All claims are managed by Claims Direct Access (CDA), a Prime affiliated company.

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Online Incident Reporting Form

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