FILE A CLAIM

* Name

Alphanumeric characters only. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Home Phone

Please enter a valid phone number - 555-555-6666. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Cell Phone

Please enter a valid phone number - 555-555-6666. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Do you consent to having United Security Insurance Company contact you about your claim via SMS/text messaging?

Yes, I consent No, I DO NOT consent

* Policy Number

Alphanumeric characters only. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Policy Holder Name

Alphanumeric characters only. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Policy Holder Address

Alphanumeric characters only. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Policy Holder City

Alphanumeric characters only. Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.

* Policy Holder State

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* Policy Holder ZIP Code

ZIP Code must be 5 or 9 numeric digits with hyphen Please enter a valid ZIP Code and territory. Effective Date must be tomorrow or after. Please enter a value between $0 and $95,000.