How to complete this form

Please fill in the requested details below and attach the required documentation

A QBE claim representative will typically contact you in 1 to 2 business days.

If this is an emergency or if you prefer to report your claim by telephone, please call 844.723.2524 (844-QBE-CLAIMS)

Person reporting the claim

Name Phone number Phone type Date Relation to insured

Please select your relation to the insured

Person(s) or entity listed as the "named insured" on the insurance policy.

*Insured's name (required field) Phone number *Policy number (required field) Email Address Property street address Apt. number City State Zip

*Name (required field) Email address *Phone number (required field) Property street address Apt. number City State Zip Alt. phone

*Date of loss/damage (required field) Approximate time

Please specify AM or PM

Describe how loss occurred General description damages (e.g. roof damage, theft)

Loss location (same as insured's address)

If checked, proceed to "Other information"

Street Address Apt. number City State Zip

Is the property habitable? If this is a business insurance claim, did the business have to close due to this loss? Anything else we should know

Attach copies of any invoices for emergency repairs or photos if you have any.

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Attachment 5

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The issue of this claim form is not an admission of liability or coverage by QBE Insurance