Report an Accident/Incident

Customer Information

(Enter if you wish to be contacted by email)

Claim Information

(MM-DD-YYYY)
(Please explain)

Please Read Before Submission: North Carolina General Statute 58-2-161 provides: any person who willfully and knowingly presents or causes to be presented a false or fraudulent claim or proof in support of such claim to an insurer for the payment of a loss…under an insurance policy or certificate of coverage, or prepares, makes or subscribes to a false or fraudulent proof of loss to an insurer with the intent that the same may be presented or used in support of such claim is subject to being charged with a felony and, if convicted, shall be punished as a Class H felony.

Send (*) denotes a required field.