Report a Claim | Glacier National Claims Services

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1Policy Information

Insured Name *

Please enter the insured name.

DBA (if applicable)

Primary Contact Name *

Please enter the primary contact name.

Primary Contact Email *

Please enter a valid email address.

Primary Contact Phone *

Please enter a valid telephone number.

Policy Number *

Please enter the policy number.

Primary Contact Address *

Please enter the primary contact's address.

2Claimant Information

Claimant Name *

Please enter the claimant's name.

Claimant Telephone Number *

Please enter a valid telephone number.

Claimant Email *

Please enter a valid email address.

Claimant Address *

Please enter the claimant's address.

3Loss Information

Date of Loss *

Please enter the date of loss.

Time of Loss *

Please enter the time of loss.

Exact Location of Loss *

Please enter the exact location of loss.

Description of Injury, Loss, or Damage *

Please provide a description (at least 10 characters).

Be as specific as possible — what happened, what was affected, and any immediate actions taken.

Scope of Work *

Please describe the scope of work.

Date Work Started

Date Work Ended

Witness Contact Information (if available)

4Claim Submitted By

Claim Reported By *

Please enter your name.

Relationship to Claim *

Please select a relationship to the claim.

Contact Email *

Please enter a valid email address.

Additional documents or information may be requested by your adjuster after submission.

5Legal Disclaimer

For your protection, this information is provided as required by applicable State and Federal law. Any person who knowingly presents false, fraudulent, misleading, incomplete or misleading facts or information or aids, abets, solicits, or conspires with any person to do so, for the purpose of obtaining insurance coverage, amending insurance coverage, seeking insurance benefits or to make a claim for the payment of a loss, is unlawful and is guilty of a crime and may be subject to fines and confinement in state or federal prison.

I have read and understand the above notice, and I certify that the information provided in this form is true and accurate to the best of my knowledge. *

You must acknowledge this notice before submitting.

Or call us at (888) 681-1230