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Claim Reporter Contact Information

(please include area code)
(please include area code)
(please include area code)

Wilson Mutual Policyholder Information

(please include area code)
(please include area code)
(please include area code)
(Person we can contact regarding this claim)

Loss Information

mmddyyyy
(include city and state)

Injured or Damaged Party/Other Party Property Damage (not the policyholder)

Other Party's Name, Address, and Phone

(please include area code)
(please include area code)
(please include area code)

Other Party Injury/Damage Info

Were there any injuries?
Were there any witnesses?

Additional Comments:

FRAUD WARNING

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

You must click this button and wait for the confirmation on your screen, otherwise your claim will not be transmitted.