REPORT A CLAIM

Please complete and submit the form below, or contact our claims department at (800) 595-6393.

(*Denotes required fields)

I am insured with Rider or reporting a claim on behalf of an insured.

I was involved in an accident with a Rider Insured.

CONTACT INFORMATION* Denotes Required Field)

*Name:   

*Address:   

*City:      *State:      *Zip:   

*Telephone:   

*Email:

INSURED INFORMATION    

*Name:

Address:

City:   State:   Zip:

Telephone: (Home):  (Work):  (Cell):

Email:

*Policy Number:   

*Year / Make / Model:

Vehicle Identification #:

Is the vehicle financed?: Choose Yes No  

If yes, name of Lienholder:

PASSENGER (if any)

Name:

Address:

City:   State:   ZIP:

Telephone: (Home):  (Work):  (Cell):

Injuries?: Choose Yes No   If yes, please describe below:

OTHER PARTY INVOLVED (Vehicle Owner/Driver)

Name:

Address:

City:   State:   ZIP:

Telephone: (Home):  (Work):  (Cell):

Injuries?: Choose Yes No   If yes, please describe below:

ACCIDENT INFORMATION

*Date of Accident: (mm/dd/yyyy)

*Location of Accident:

*Police Report Filed?: Choose Yes No   If yes, Case Number:

*Location of the Bike:

*Brief Accident Description:

*Was passenger involved?: Choose Yes No

ACCEPTANCE OF THIS CLAIM REPORT IS NOT AN ACKNOWLEDGEMENT OF COVERAGE OR ADMISSION OF LIABILITY, AND ALL INFORMATION SUBMITTED IS SUBJECT TO REVIEW FOR COVERAGE VERIFICATION AND LIABILITY EVALUATION.