Claim Form

Claim Form
	First & Last Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
Date of Loss:		Time of Loss:
Location of Incident/Loss:
Description of Incident/Loss:
Were the authorities called:
	Additional Information that might help expedite the claim process:

By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim. Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Tri-County Insurance
800 Industrial Drive S #206
Sauk Rapids, Minnesota 56379
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Phone: 320-251-2552
Fax: 320-253-5682
Toll Free: 888-480-1677

53 Hwy 23 E
Foley, MN 56329
Toll Free: 888-480-2552
Phone: 320-968-6496
Fax: 320-968-9913

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