Claims


Loss Run Request Form
Named Insured:
Insured Mailing Address:
City:
State:
Zip:


Check applicable line of business and enter policy effective dates:

General Liability	Policy Effective Dates(s):
Property	Policy Effective Dates(s):
Umbrella	Policy Effective Dates(s):
D & O	Policy Effective Dates(s):
Workers' Compensation	Policy Effective Dates(s):

If you are not the current broker-of-record we require an authorization signed by the named insured to release this information to you. Please print this screen and fax it with the written authorization to 212-297-3131; Attention: Claims Status Update Request, or email it to DPGClaims@distinguished.com.

Agent/ Broker Requesting Info
Name:
Company:
Phone #:
Fax#:
Email: