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Welcome to Summit America
Phone 1-913-754-5617
Fax 1-913-327-0201
Claims 1-800-237-2917
 
  Ask us a Question/E-mail
Online Claim Form  
*fields are mandatory
This is for notice/record only: (what's this?)

Preparer
           
* Title:  
* First name: * Last name:
  Company name (if applicable):        
Address: City:
     
State: Zip:
* Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
* E-mail:
  

Insured Information
           
       
* Title:  
* First name: * Last name:
  Company/organization/club name
(if applicable): 		       
* Address: * City:
     
* State: Zip:
* Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
E-mail:
  

Agent Information
           
       
  Agency name:        
Contact first name: Contact last name:
Address: City:
     
State: Zip:
Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
E-mail:
  

Claimant/Witness Information
 
Claimant
           
* Title:  
* First name: * Last name:
  Address: Date of birth: Pick a date
      Driver's license/Social security number:
  City:   State/province:
  Zip:   Country:
  Phone number:   Type:
  Phone number:   Type:
  E-mail:
  
* Was the claimant a:
    
 
Add another claimant
 
Witness
           
Title:  
First name: Last name:
  Address:
     
  City:   State/province:
  Zip:   Country:
  Phone number:   Type:
  Phone number:   Type:
  E-mail:
  
Add another witness

Loss Information
   
* Describe the loss and what happened. Include any injuries or property damaged or stolen.
 
* Date of loss: Pick a date Policy number:  
         
Loss Location
 
 
*Street address (no PO box):   *City:  
    *State:  
  Zip:  
       


Additional Information
         
Details/comments: