Mark Mask Insurance

Please note: Submitting a claim at this web site does not confirm coverage or authorize payment. A claims representative will verify coverage and contact you to complete the claims process.
* Required fields
Policy Number:	*
Your Name:	*

Contact Person: Whom should the adjuster call to settle your claim?
Name:	*
Home Phone:	*
Work Phone:	*
Email:	*
Best Time to Call:

Authority Contacted:
Police/Fire Dept:
Report Number:

Claim Information:
Date of Loss:	*
Location of Claim:	*
Cause of Loss:
* Describe Your Damages/Loss:

Emergency Services Needed: Temporary Shelter Required? NoYes Windows Required Board-Up? NoYes
Other?

Persons Injured:
Name:
Address	City
State	Zip Code
Phone Number:
Nature of Injuries:
Cause of Injuries:

Comments and/or Other Information:

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Thank you.

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