Create a Claim Report - Residential

Your Wawanesa Insurance policy number is required to complete this claim form.

If this is a claim emergency, please call 1-844-929-2637. We're available 24/7.

* indicates a required field

Your Information

	Wawanesa Insured Broker
First Name*
Last Name*
Please type at least one phone number below *
Home Phone Number
Business Phone Number	ext.
Cell Phone Number
Email Address
Insurance Company Name
Insurance Company Policy #

Loss Information

Our Policy Number*	Help
Date of Loss*	(mm/dd/yyyy)
Time of Loss*	HH 01 02 03 04 05 06 07 08 09 10 11 12 : MM 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

Describe the Accident or Incident*

Our Insured Information

Loss Location

Same as insured's address
Address
City*
Country	Canada United States of America
Province*	Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code
State*	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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
Zip Code

Police Report

Mortgagee

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