Agent Claim Request - Klein-Dickert Co, Inc

Agent Claim Request Form

You can also print a blank copy of the Agent Claim Request form and fax it to us.

* = Required Fields

Agency Information

* Agency Name	* Agency Phone
* Insurance Company	* Name of Person Submitting Claim
* Email Address of Person Submitting Claim
Policy Holder Information
* Policy Holder Name	* Policy Holder Street
* Policy Holder City	* Policy Holder State/Zip
* Policy Holder Telephone Home Work Cell
* Policy Number	Claim Number
* Deductible Amount $	Date of Loss
Cause of Loss
Vehicle Information
* Vehicle Year	* VIN (Vehicle Identification Number) (17 digits required)
* Vehicle Make	* Vehicle Model
* Vehicle Type Car SUV StationWagon Truck	Van Mini Van Other
Service Information
* Type of Work If Other -
Send Claim to: Green Bay Office Madison Office Brookfield Office Marinette Office Oshkosh Office
Special Instructions
NEW - Security Code For added security, we ask you to please enter the code displayed to the right into the text box below.
A confirmation e-mail will be sent to the person submitting the claim. If you do not receive the auto reply, please call or resubmit.
NOTE: Klein-Dickert will not share any information with any other company or organization.

1-800-FIX-GLASS (1-800-349-4527)
info@klein-dickert.com