Report Claim - Greater Insurance Service

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REPORT A CLAIM

WE PROVIDE INSURANCE COVERAGE FOR MINNESOTA ONLY
Please fill out the form and submit it to us. We will contact you as soon as possible. If you prefer to give information over the phone, fill out the * areas only and we will give you a call, or print this out and mail or fax it to us.

Name:	*
Address:	*
City:	*
State:	*
ZIP:	*
Home Phone:	*
Email:	*
Work Phone:
Cell Phone:
Please provide the date and a brief description of your claim: