West Suburban Insurance Agency - Butler, WI West Suburban Insurance Agency Claims Form
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Commercial Insurance		 This section is for the private use of our customers only. Please record all pertinent information below. We will personally contact you, on the next business day, before filing your claim, to verify all information provided and discuss the details.

If this is a Homeowners Claim, and your Home or Property has sustained damage, please take whatever steps necessary, in the interim, to secure your home or property from further damage. An adjuster will contact you, usually within 24-48 hours. Please be sure to leave a daytime and evening phone number.

If this an Auto Claim, and your car is not driveable, please have it towed to the nearest repair center for an estimate. If your car is now at home, please wait for an adjuster to call before taking it in for repairs. If you, or anyone else has been injured, please seek medical attention immediately. It is not necessary to wait for an adjuster to call. Your physical well-being, and that of your passengers, takes precedence. Thank you.

WEST SUBURBAN INSURANCE AGENCY
AUTO/PROPERTY LOSS NOTICE

Insured Name
Type of Loss
Date of Loss
Time of Loss AM/PM?

IF AUTO LOSS
Driver of Vehicle
Vehicle Involved (year, make, model)
Where did loss occur?

Were there any injuries?
If yes, please provide details...

Type of Auto Loss (Select all that apply)
Collision Theft Vandalism Deer Hit Injury

IF HOME LOSS
Type of Home Loss (Select all that apply)
Fire Theft Weather Water Personal Injury

Please provide all known information regarding
the circumstances of this loss:

Any additional information regarding other
drivers or details that you may want to provide?

Your Name
Day Phone () - Eve Phone () -
Email

Thank you for using our website to submit your claim. We will acknowledge receipt of your claim via return email and a personal phone call. All information provided is considered strictly confidential.


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Member Of The Professional Insurance Agents Of Wisconsin West Suburban Insurance Agency, LLC
3620 N. 126th Street
Brookfield, WI 53005
Phone: 262-783-6275
Fax: 262-783-6211
Toll-Free 800-564-0801
sales@insurewisconsin.net

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This text may be reproduced in electronic media so long that it remains completely intact and includes this notice. Hard copy reproduction requires written permission of West Suburban Insurance Agency.