FNOL

If you're an insurance agent or third-party, please complete this form to report a claim and we'll be in touch. If you're a policyholder with Coterie, go here to report a claim for faster service.

Carrier Name

Policy Number

If policy number is unknown, type in UNKNOWN

Date of Loss

Date

If your loss date is outside of the policy period, please contact your insurance agent. If you need additional help, contact Coterie at 855-566-1011.

Policyholder Company Name

Policyholder Company Address

Street Address

Street Address Line 2

CityState

Zip Code

Policyholder Contact Name

First NameLast Name

Policyholder Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Policyholder Contact Email

example@example.com

Is the loss location different than the above?

Loss Location

Street Address

Street Address Line 2

CityState

Zip Code

Choose a Loss Coverage Type

What happened in the loss? (Please include as much info as you have available)

What was damaged in the loss? (Please include as much info as you have available)

What happened in the loss? (Please include as much info as you have available)

What type of GL claim?

What was damaged in the loss? (Please include as much info as you have available)

Do you have the damaged property owners' information?

Damaged Property Owner Name

First NameLast Name

Damaged Property Owner Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Damaged Property Owner Email

example@example.com

Damaged Property Owner Address

Street Address

Street Address Line 2

CityState

Zip Code

Injury Loss Type

Part of Body Injured

Claimant Date of Birth

Date

Do you have the injured party's information?

Injured Party's Name

First NameLast Name

Injured Party's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Injured Party's Email

example@example.com

Injured Party's Address

Street Address

Street Address Line 2

CityState

Zip Code

What happened in the loss? (Please include as much info as you have available)

What was damaged in the loss? (Please include as much info as you have available)

Do you have the impacted party's information?

Impacted Party's Name

First NameLast Name

Impacted Party's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Impacted Party's Email

example@example.com

Impacted Party's Address

Street Address

Street Address Line 2

CityState

Zip Code

Was there a witness?

Witness Name

First NameLast Name

Witness Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Witness Email

example@example.com

Witness Address

Street Address

Street Address Line 2

CityState

Zip Code

Your Name

First NameLast Name

Agency Name

Attorney Firm Name

Your Relationship

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Your E-mail

example@example.com

Your Relationship to the Claim

Please confirm the following

Coterie's Privacy Policy (https://coterieinsurance.com/legal/privacy/) and Privacy Notice to Claimants (https://coterieinsurance.com/legal/claimants/) explain how we collect, use, disclose, and protect personal information. By reviewing this policy and continuing to use our services, you acknowledge and consent to our handling of your data and the data you are submitting on behalf of the claimant as described. You are required to review the full policy to understand our data practices and your rights. You may withdraw your consent at any time by contacting privacy@coterieinsurance.com. Please note that withdrawing consent may limit or prevent access to certain services that rely on your data, as permitted by applicable law.

Optional-Texting Consent

As part of the Coterie Insurance digital payments option we can also send you a text message to speed up your payment processing. These texts would include invitation to submit your payment details, reminders, confirmations, and alert messages. If you do sign up for texting message and data rates may apply. You can opt out at any time by sending STOP to 63539 or you can call us for help at 855-460-1420.

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Report a Claim

Policyholder Info

Business Owner Policy (BOP)

General Liability (GL)

Damage Claim (GL)

Injury Claim (GL)

Professional Liability (PL)

Witness Info

Acknowledgment