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Claims

Please fill out and submit the form below to submit General Liability claims.
For all other claim types, please contact Larissa Avila at lavila@shieldins.net.

* required field
Insurance Program:

Person submitting the claim

First Name: Last Name:
Phone: Email:

Producer

Company Name:
First Name: Last Name:
Street: City:
State: Zip Code:

Insured

Name of Business:
First Name: Last Name:
Policy #: Effective Date:
Street: City:
State: Zip Code:
Phone: Email:

Claimant

First Name: Last Name:
Policy #:
Street: City:
State: Zip Code:
Phone: Email:

Occurrence

Location of damaged premises

Date of Loss:
Street: City:
State: Zip Code:
Description of occurrence:

Injured/Property Damaged

First Name: Last Name:
Street: City:
State: Zip Code:
Phone: Email:
Describe injury, where taken, what was the injured doing, describe property, estimate amount, where can property be seen, when can property be seen.:

Witnesses

First Name: Last Name:
Street: City:
State: Zip Code:
Phone: Email:

Person to Contact

First Name: Last Name:
Street: City:
State: Zip Code:
Phone: Email:

Shield Commercial Insurance Services, Inc.
43-725 Monterey Ave, Ste A. Palm Desert, CA 92260
Tel: 760-345-9029 Fax: 800-345-4851
CA License Number: 0E67754