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Claims

Please fill out and submit the form below for General Liability claims.
For all other claim types, please contact Celeste at celeste@shieldins.net.

* required field

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:
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:
Description of occurrence:

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