Report a Claim

Please refer to the List of Company Claim Contacts to report the claim directly to your insurance company. If you do not see your insurance company listed, please either complete and submit the Claim Reporting Form or contact our office at 816-781-4922 and ask for Pat Abernathy. You can also reach Pat via Fax at 816-781-8050 or e-mail her at patabernathy@gmpeters.com.

NOTE: Workers' Compensation claims need to be reported directly to the insurance carrier.

General Liability

Auto

Property

*Your Company Name:

*Contact Name:

*Telephone number of loss location (xxx-xxx-xxxx)

*Date of Accident

Time of Accident

AM

PM

*Address where the the indicident occured:

County

*Please give a description of the incident

Authorities were contacted? (Police, fire, ambulance)

If so, why?

Report Number was given?

If so, list number:

*What is the name of the injured party:

Social Security Number:

Date of Birth:

Marital Status:

How Many Dependents:

*Home Phone:

Work Phone:

Contact at home or work?

Home

Work

What part of the body?

What treatment was given?

*Give a description of the injuries:

Name and address of a witness to the incident:

Phone Number where witness can be reached:

Anything else related to the accident you would like to add: