227 S. Division Street Zelienople, PA, 16063 andrew@beneighgroup.com
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Claim Submission

First Name *
Email *
Policy Number
Date of Incident
Type of Claim
Last Name *
Phone *
Insurance Carrier
Policyholder Name
Remote Documents Link Place a link to your files in google drive, dropbox, or other cloud storage medium here. Ensure sharing is set to public for the file/folder URL placed here.
Brief Description of Incident *
File Upload Only .pdf files will be accepted by the form submission. Attaching any other type of file will prevent your submission from reaching our team.
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I have not include sensitive personal information, such as Social Security numbers, banking details, or specific medical information in this form. I understand an agent will collect these details securely during a follow-up.
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