Claim Request - Coughlin Insurance Services

Claim Request Form
The following form is provided to you for making claim requests on your existing policy.

Please select the type of claim you are making.

We will review your request and we will contact you for more information by the end of the next business day.

You must press the submit button before leaving the page for the request to go through.
Your First Name*
Your Last Name*
Company Name (if Business)
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Telephone Number*
Your Email Address*
Current Insurance Information
To what type of insurance do you wish to make a claim?*
Policy Number*
Policy expiration date?*
MM slash DD slash YYYY
Date of the event for which you are making a claim*
MM slash DD slash YYYY
Describe the event for which you are making a claim*
CAPTCHA

Coughlin Insurance Services, Inc.
178 Myrtle Boulevard, Floor 2, Larchmont, NY 10538
Toll Free : (800) 542-0661
Tel: (914) 834-1234 Tel: (212) 593-0200

Claim Request Form

Current Insurance Information