Submit a Claim — Rockville Risk Management

SUBMIT NEW CLAIM

Rockville Risk Management Associates prides itself on handling claims expertly and expeditiously. To report a claim, please fill out and submit one of the forms below.

Rockville Risk Management Property Claim Submission

Name

First Name

Last Name

Email Address

Company

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference Number

RRM Program Number

Insured Information

Insured Name

First Name

Last Name

Insured Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insured Home Phone

(###)

###

####

Insured Work Phone

(###)

###

####

Loss Information

Loss Type

Date of Loss

MM

DD

YYYY

Estimated Damage Amount

$

Loss Description

Policy Information

Policy Type

Company

Policy Number

Effective Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Is Property Mortgaged

Yes

No

Mortgagee Name

First Name

Last Name

Mortgagee Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Enter Applicable Coverage Limits

Additional Coverages

A: Dwelling

B: Other

C: Personal Property

D: Loss of Use

Deductions

Exclusions/Coverage Modifications

Additional Insurance Details

Comments/Special Instructions

RRM General Liability Claim

Name

First Name

Last Name

Email Address

Company

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Claim Number

RRM Program Number

Insured Information

Insured Name

First Name

Last Name

Insured Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insured Home Phone

(###)

###

####

Insured Work Phone

(###)

###

####

Loss Information

Date of Loss

MM

DD

YYYY

Describe the Accident

Damage Information

Injuries

Yes

No

Injured Name

First Name

Last Name

Injured Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Injured Phone

(###)

###

####

Gender of Injured

Male

Female

Property Damage

Yes

No

Property Owner Name

First Name

Last Name

Property Owner Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Property Owner Phone

(###)

###

####

Property Description

Location of Property

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Estimated Damage Amount

$

Witnesses

Any Witness of the Loss?

Yes

No

Witness Name

First Name

Last Name

Witness Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Witness Phone

(###)

###

####

Policy Information

Insurance Carrier

Policy Number/ID

Coverage Effective Date

MM

DD

YYYY

Coverage Expiration Date

MM

DD

YYYY

Additional Info

Comments or Special Instructions