Submit your claim...
Quickly, Accurately, 24 Hours a Day
...or call us at (905) 878-7217 We'll take your claim
information over the phone....
Get your claim to us quickly....
Your company information is on the yellow background form
 Police information is on the blue background form
The incident information is on the green background form
Commercial Claim Form
Date/Time of Incident 		Time:
Company Name
Street Address
Unit No.
City
Postal Code
Contact Person Name
E-mail
Daytime Telephone Number
Evening Telephone Number
POLICY NUMBER
Insurance Company
Reported to Police?
Please Check One
YES NO
Officer's Name
Badge Number
Occurance Number
Police Force/Detachment:
 (Opp, Halton, Metro etc.)
Charges Laid?
Incident
Information
Where did the
incident occur?
Details of Incident
Injuries?
Do you have any other info
that might be helpful?
Submit your claim...
Quickly, Accurately, 24 Hours a Day
...or call us at (905) 878-7217 We'll take your claim
information over the phone....