Insurance Claim Form

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410-838-1851

ONLINE QUOTE CENTER

York Insurance Services Inc
2011 Rock Spring Road,
P O Box 900
Forest Hill , Maryland 21050
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Phone: 410-838-1851
Fax: 410-893-4187
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CLAIM FORM

We are licensed in Maryland, Pennsylvania, Virginia and Delaware. We can provide insurance coverage and quotes in these states only.

Claim Form
	First & Last Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
Date of Loss:		Time of Loss:
Location of Incident/Loss:
Description of Incident/Loss:
Were the authorities called:
	Additional Information that might help expedite the claim process:

By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim. Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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