DCM Claims Notification

DTW Claims Management LLC

Claim Notification
Please use this form to report a claim. You will need the following information:
- Policy number or reference
- Date of loss
- Your correspondence address (as noted on your policy schedule or certificate of insurance)
- Your contact details (telephone number and email address)
If you are experiencing difficulties completing this form, do not have all of the required information or would prefer to notify us by telephone please call (404) 666 4450 and one our team will assist you.

Following your sumbission, one of our claim handlers will contact you within 24 hours to discuss your claim. We may ask you to provide more information so that we can assess your claim.
Please indicate whether you are*

A policyholderAn agent of the policyholder / the coverholder
I am

The coverholderThe policyholder's brokerA loss assessorOther
Agent's business name*
Your business name
Agent contact name*

First NameLast Name
Agent email address*
example@example.com
Agent phone number*

Area CodePhone Number
Does this policy cover a business?*

YesNo
Policyholder's business name*
Contact name*

First NameLast Name
Policyholder's name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Policyholder's telephone number*

Area CodePhone Number
Policyholder's email address
example@example.com

Claim Notification

Details of Loss
Date of loss*

MonthDayYear
Date
Loss type*

Wind damageFlood damageOther
Please state the type of loss
Property Type*

DomesticCommerical
Please describe the nature and extent of the loss as completely as possible.*
Would you like to upload any supporting documentation?*

YesNo
Select files to upload

Browse Files
Maximum file size - 10MB, multiple files may be uploaded Cancelof

Claim Notification

Declaration
I confirm that the information provided within this submission is accurate and complete to the best of my knowledge. I understand that if this is not the case a decision regarding the claim may be delayed while additional information is collected.

I understand that submission of this form does not constitute acceptance of liability and that a decision will only be made once all information relevant to the loss has been received and assessed.
I have read the above statement and confirm the information provided is accurate and complete*

YesNo
Name of individual completing this notification*

First NameLast Name
Please tick the box*
Should be Empty:

DTW Claims Management LLC