Submit Your Claim - Agilis Risk Services

Basic Information

Name *

Company *

Phone Number *

Email *

Claim Number *

Insured Name and Contact Information

Insured

Insured Phone Number

Insured Email

Street Address

Apartment, Suite, etc

City

State / Province

Zip Code / Postal Code

Loss Information

Street Address

Apartment, Suite, etc

City

State / Province

Zip / Postal Code

Date of Loss (DOL)

Loss Description

Claimant's Name and Contact Information

Name

Phone

Email Address

Street Address

Apartment, suite, etc

City

State / Province

ZIP / Postal Code

Claimant Attorney Information

Type of Assignment

Statement Requirements

Select all that apply

Insured

Claimant

Witness/Others as needed

Reports

Select all that apply

Police

Fire

911 Calls

CAD

Photos/Scene Diagram

Select all that apply

Photos

Diagram

Social Media/Background Check

Instructions/Additional Details

Please provide any additional instructions or details