Tools BSRO Claims

Submit a Claim
Is your claim over $3,000?
This form is only for claims over $3,000.

Please contact AssuredPartners at (800) 860-0090 if you have any questions.
Employee Information

Please tell us about yourself and what store you work for.
First Name
Last Name
Employee ID
Your Email Address
Store Name
Store Phone Number
Format: (000) 000-0000.
Store Address
Street Address
City
State
Zip Code
Claim Information

Please provide details about your claim
Nature of Loss
Date of Loss

MonthDayYear
2 digit month, 2 digit day, 4 digit year
District Manager Notified?
Estimated Loss
Comments / Questions
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Submit a Claim