Claims – Insure with BiZ

Text/Call (773) 777-1040 | Email Us at insurance@biz1040.com

Please complete the form below with as much detail as possible. You may upload photos, police reports, claim documents, or other supporting files.

If this is an emergency or someone is injured, call 911 first. Submitting this form does not guarantee coverage or replace any required carrier claim process.

Your Information

First Name *

Last Name *

Email Address *

Phone Number *

Business Name, if applicable

Policy Information

Policyholder Name *

Policy Number

Insurance Carrier

Policy Type *

Please describe the policy type

Claim Information

Type of Claim *

Date of Loss / Incident *

Time of Loss / Incident

Location of Incident *

Please describe the claim type

Describe what happened *

Auto / Vehicle Accident Details

Your Vehicle Year / Make / Model

VIN

Driver Name

Any passengers?

Other Vehicle / Party Information

Was the vehicle towed?

Injury Details

Was anyone injured?

Was medical treatment received?

Briefly describe the injury, if any

Property Damage Details

What property was damaged?

Estimated Damage Amount

Describe the damage

Police Report / Authorities

Was a police report filed?

Police Report Number

Police Department / Agency

Officer Name, if known

File Uploads

Upload photos from the accident, damage, or incident

You may select multiple files. Accepted files: PDF, JPG, PNG, HEIC, DOC, DOCX.

Upload police report, exchange form, or incident report

You may select multiple files.

Upload any additional claim documents

Examples: estimates, invoices, medical documents, carrier letters, tow receipts, repair documents, loss details, or other supporting files.

Additional Information

Best time to contact you Anything else we should know?

This form is for claim intake and communication purposes only. Coverage, claim handling, and payment decisions are subject to the policy terms and the insurance carrier.