Association Claims - Atlantic Shield Insurance Group

Association Name/Name on Policy*
Management Company
Incident Address
Address*
Street Address Address Line 2 City State ZIP Code
Property Manager First & Last Name
Property Manager Email
Property Manager Contact Phone Number
Additional Contact First & Last Name
Additional Contact Phone Number
Date of Loss*
Time of Loss

: Hours

Minutes

AM/PM
Type of Claim*
Was anyone injured? If yes, please answer the following three questions.*
- Yes
- No
First & Last Name of Injured Party
Phone Number of Injured Party
Did the Injured Party Go to the Hospital?
- Yes
- No
Was a Police Report Filed?
- Yes
- No
Details of Incident*
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Incident Address