Report A Loss

Call (248) 651-7321 8:30 a.m. to 5:00 p.m. EST to speak to a member of our licensed & accredited staff.


Please email us at or complete the form below:

*Name of Insured: 
Date and Time of Loss
* Today's Date:
* Date of Loss:
Time of Loss:
  AM  PM
Person Reporting Claim
* Name:
* Phone:

Agencies Involved
Police Report Number (if applicable):
Fire Dept Report Num. (if applicable):
Other agencies or comments:
Location and Description of Loss
* Location of Loss :
* Description of Loss :

If there is no more relevant information forward to submit button, otherwise continue with the rest of the form

If Person Injured
Injured Name :
Injured Phone:
Injured Address:
Extent of Injury:

If Property Damaged
Describe Property and Location  
(house, building, fence, auto, etc.):
Property Owner's Name :
Property Owner's Phone:
Estimated amount to repair::
Property Owner's Address :
Describe Damage to Property :
If property is a vehicle, 
where can it be seen: 

If Vehicle Caused Damage
Vehicle Year:     Make:     Model:      License Plate Num: 
Owner's Name :        Owner's Phone:
Vehicle Owner's Address:
Driver's Name :         Driver's Phone:
Driver's Address:      
Driver's Relationship to Insured :                      Vehicle used with permission?:  YES   NO     
Driver's Date of Birth :            Driver's License Number:          State Issued:
Purpose of Use:
Violations or Citations Issued:
Any other pertinent information:
Form Submission Agreement:
I agree that by submitting this form the questions were answered to the best of my ability.

I am authorizing Whims Insurance to act upon the information given. 

Please check if you agree to these terms: 

After the form submittal, you will see a confirmation on your screen that the form has been sent. 
We will personally send you an email confirmation once we have received and evaluated your request.


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