Richey ~ Barrett Insurance
A Professional Insurance Agency
Westlake, Ohio 44145 - 5611 Phone: (440) 835-4800 / Fax: (440) 835-6991		  
 
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Report A Claim

INSURED INFORMATION
Policy Holder's Name:
  *
Your Name:
  *
E-Mail:
Residence Phone:
*
Cell #
   
Business Phone:
   
Fax:
   
Street Address:
        
P.O. Box/Suite:
          
City:
          
State:
          
Zip Code:
          
LOSS INFORMATION
 
Date of Loss:
Time of Loss:
 
Type of Loss:
(Auto, Property, Liability, etc.)
 
Location of Loss:
 
Police Department:
 
Police Report Number:
 
 If Auto, Provide the following for the Policy Holder's Vehicle
 
Name of Driver:
Vehicle:
OTHER PARTY INFORMATION
 
Name:
 
Home Phone:
Work Phone:
Cell Phone:
 
Street Address:
 
P.O. Box/Suite:
 
City:
State:
Zip Code:
     
 
Insurance Company:
Policy Number:
 
Vehicle:
License Plate#:
SUPPLEMENTAL DETAILS...
 
Description of Claim:
 
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