Report a Claim

In the event of an incident or potential claim, please complete this form. This Form will be sent to the Rubin Insurance Agency. Or please contact us at (858) 457-5720.

Loss Information

Insured Name *
Insured Address
Location of Loss *
Loss or Discovery Date *
Time of Loss
Person Reporting *
Date
E-Mail *
Phone Number *
Description of Loss:
Other parties involved (name, address, phone number, description of injuries/damages)
Witnesses (name, address, phone number) *

Incident Reported to:

Police Department	Yes No
Fire Department	Yes No
If yes please supply the Case Number
Additional comments:

* = Required Field

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