Name Are you the policyholder? Yes No If no, what is your relationship to the policyholder? If no, what is the policyholder name? Policy Number Property Address of Location of Loss Address of Location of Loss City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Zip Code Contact Cell Phone Number Contact Home Phone Number Contact Email Date of Loss Description of Cause of Loss Description of Damages Is the Property Livable? Yes No If no, has the property been secured or boarded? *Please note you will be contacted by a Claims Representative with Michigan Basic’s third party administrator, Broadspire, within one business day (not including weekends or holidays). For emergency board up services, please call 313-877-7400. CAPTCHA
