ONLINE CLAIMS REPORTING
To report a personal lines claim, formerly issued by Fireman's Fund Insurance Company, please contact 1.800.945.7461.
If you are reporting a Commercial Lines, Entertainment or Farm and Ranch Claim, please proceed with the appropriate link below.
General Instruction
When submitting a new loss, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked with an asterisk.
 
If required information is unknown at the time of your web submission, please contact 1-888-347-3428 to report your new loss.
 
The Accident Description field will have a 90 character limitation. Additional information can be entered in the final remarks area of the submission. No information will be transmitted until you click the 'Submit Form' button at the bottom of the form.
 
Emergencies
If your loss is severe, and you need immediate assistance, please call 1-888-347-3428.
 
* Indicates required fields.
Preparer
Title
First Name * Last Name *
Street City
State Zip Code Country/Region
Primary Phone * Primary Ext Type
Alternate Phone Alternate Ext Type
Email *
Email Confirmation *
Person Reporting the loss? *
Additional email addresses may be entered into the Remark section below.
General Loss Information
Description of Accident*
Date of Loss * Time of Accident : :
Policy Number * Policy Type *
Was a Lawsuit Filed? If Yes, Date Served? Is this Report for Record only? *
Loss Location
Street
City *
State * Zip Code Country/Region *
Insured Information
Same as Preparer Information
Please enter either Individual or Business Name as it appears on the policy.
Title  
      First Name Last Name *
OR
Business Name *
Please enter information below as it appears on the policy.
Street City *
State * Zip Code Country/Region
Primary Phone * Primary Ext Type
Alternate Phone Alternate Ext Type
Email
Insured Contact
Title
First Name Last Name
Street City
State Zip Code Country/Region
Primary Phone Primary Ext Type
Alternate Phone Alternate Ext Type
Email
Insured Vehicle
Year * Make * Model
Estimate Amount of Damages (USD)
Primary Damage
Insured Driver
Insured Driver
Title Relationship to Insured
First Name Last Name
Street City
State Zip Code Country/Region
Primary Phone Primary Ext Type
Alternate Phone Alternate Ext Type
Other Loss / Damage Info
Kind of Loss* Property Damage Type
If auto loss, complete the vehicle fields below.
Damaged Vehicle Year Damaged Vehicle Make Damaged Vehicle Model
Estimate Amount of Damages (USD)
If other property damaged, please enter damage description below
Damage Description
Was Anyone Injured? Fatality?
Other Vehicle Owner
Please enter either Individual or Business Name, address and phone number(s) as appropriate.
Other Vehicle Owner
Title
      First Name Last Name
OR
Business Name
Please enter for Individual or Business owner.
Street City
State Zip Code Country/Region
Primary Phone Primary Ext Type
Alternate Phone Alternate Ext Type
Email
Other Vehicle Driver
Other Vehicle Driver
Title
First Name Last Name
Street City
State Zip Code Country/Region
Primary Phone Primary Ext Type
Alternate Phone Alternate Ext Type
Email
Injured Party
Injured Party
Title
First Name Last Name
Street
City
State Zip Code Country/Region
Primary Phone Primary Ext Type
Alternate Phone Alternate Ext Type
Email
Describe Injury
If multiple injured parties, please enter additional names, addresses and phone numbers of all parties in the Remarks section below.
Additional Information
Remarks
Agent Email
Same as Preparer
Please provide the agent's email address. By providing this information, you are authorizing Allianz to email the details of the loss to the email address below.
Email
Email Confirmation
Attachments
Please use the Browse button to add files to your First Notice of Loss. Only the following file types are allowed: .xls, .xlsx , .jpg, .bmp, .doc, .docx, .txt, .tif, .pdf
You may attach up to six documents to your new loss for a total of 8 MB in size. If you have additional supporting documentation you may send them directly to your adjuster after they have made contact with you.
File(s) Attached   Size (KB) Action
  Remove
  Remove
  Remove
  Remove
  Remove
  Remove
 Total : 0.0 KB (0.0 MB)  
 

If you wish to print a copy of your Web First Notice of Loss, please select the Print button below BEFORE you submit your claim.

Fraud Warnings

Applicable in Alaska, Arkansas, Delaware, District of Columbia, Florida, Idaho, Indiana, Kentucky, Louisiana, Maine, New Jersey, New Mexico, Oklahoma, Rhode Island, Tennessee, Virginia, Washington and West Virginia
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, ME, TN, VA and WA, insurance benefits may also be denied. In DE, FL, ID, IN and OK any person who knowingly and with the intent to injure, defraud, or deceive an insurance company files a statement of claim containing false, incomplete or misleading information is guilty of a felony. In FL, such person is guilty of a 3rd degree felony.

Applicable in Alabama
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Applicable in Arizona
For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in California
For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison

Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Applicable in Maryland
Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicable in New Hampshire
Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New York
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicable in New York (personal automobile insurance)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

Applicable in Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Applicable in Pennsylvania (automobile insurance)
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.