Please complete the following form to submit a claim.

Select the office to send this claim to			Select Location Campbell River Courtenay Duncan Nanaimo Port Alberni Powell River Vancouver Victoria Head Office for Sorting
From (Name)
Date
Sender (Company)
Phone
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Type of Loss
Date of Loss
Claim Number
Insured
Insured (Name)
Address
Telephone
Contact Name
Contact Telephone

Coverages

Policy Number
Term
Type of Policy
Agent
Deductible

Coinsurance %
Building$
Contents$
Other		$
Other		$

Remarks

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Coast Claims Service Ltd. Head Office - Victoria Suite 6, 2727 Quadra Street, Victoria, BC V8T 4E5 Toll Free: 1-866-694-3111 Phone 250-386-3111 Fax 250-386-1473 Email: victoria@coastclaims.com