Claims Center

Report your claim with ease 24/7 online

Fill out the form below to report a claim

We are currently updating our online form for submitting claims. Please use one of the two options below.

Date
Date Format: MM slash DD slash YYYY
Insured Location Code*
Date of Loss
Date Format: MM slash DD slash YYYY
Time of Loss

: HH

MM
Carrier
NAIC Code
Policy Number

Insured Information
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Date Format: MM slash DD slash YYYY
FEIN Number(If Applicable)
Primary Phone
Type of Phone
Secondary Phone
Type of Phone
Primary Email
Secondary Email

Contact
Contact Insured
- Contact Insured
Contact Information
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Type of Phone
Secondary Phone
Type of Phone
When to Contact?
Primary Email
Secondary Email

Occurrence
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Police or Fire Department Contacted
Report Number
Describe location of occurrence if not at specific address
Description of occurrence (ACCORD 101, Additional Remarks Schedule, may be attached if more space is required)

Type of Liability
Premises: Insured is
Owners Information
Owner's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Premises
Primary Phone
Secondary Phone
Primary Email
Secondary Email

Products Information
Products: Insured is
Manufacturer's Name
Manufacturer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Product
Primary Phone
Secondary Phone
Primary Email
Secondary Email
Where can product be seen?

Injured/Property Damaged
Name (Injured/Owner)
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Secondary Phone
Primary Email
Secondary Email
Age
Sex
Occupation
Where taken
Describe Property(Type, model, etc)
Estimate Amount
Where can property be seen?
Describe injury
What was injured doing?
Employer's Information
Employers Name
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Secondary Phone
Primary Email
Secondary Email

Witnesses
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Secondary Phone
Primary Email
Secondary Email
Add Additional Witness
- Add Additional Witness
Witness 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Secondary Phone
Primary Email
Secondary Email
Add Additional Witness
- Add Additional Witness
Witness 3
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone
Secondary Phone
Primary Email
Secondary Email

Remarks (ACCORD 101, Additional Remarks Schedule, may be attached if more space is required)
Reported by:
Reported to:

Alternative ways to submit a claim

Download our claim form

Download

insure@pbibinc.com
(877) 893-7629

Claims FAQs

When should I report a claim?

As soon as possible. Contact us today to fill out your claim form.

What if my claim is less than my SIR (deductible)

If your claim is lower than your SIR, than your insurance company will not cover it.

What if my claim is not covered?

While most claims are covered, there are unfortunate instances that are not. It is best to read over your policy documents to see what is and is not covered. And you can contact your broker to discuss these exclusions with you. If you think that our decision was wrong, you are welcome to submit more information/evidence to prove your claim is covered.

Contact Us



2102 Business Center Drive, Ste. 280
Irvine, CA 92612



877-893-7629



Claims Center

Report your claim with ease 24/7 online

We are currently updating our online form for submitting claims. Please use one of the two options below.

Insured Information

Contact

Contact Information

Occurrence

Type of Liability

Owners Information

Products Information

Injured/Property Damaged

Employer's Information

Witnesses

Witness 2

Witness 3

When should I report a claim?

What if my claim is less than my SIR (deductible)

What if my claim is not covered?

Contact Us

877-893-7629

info@pbibinc.com or Chat With Us