Claim Report Form

Please complete the following form and we will contact you to obtain additional information.

*Required Fields

Contact Information
Business Name
*Contact Name
*E-Mail
*Insured with Scott Umland Insurance Services, LLC?
Policy Number
*Date of Loss
Description of Loss


Contact Information
Contact Name
Address
City
State
Zip
Home Phone
Work Phone
*Best Place to Contact
Best Time to Contact

Scott Umland Insurance Services, LLC

2028 Jackson Street

P. O. Box 236

New Holstein, WI 53061

Phone: (920) 898-5755