Goodville Mutual Casualty Company

Policy Holder Information
Policyholder Name: *
Address: *

City/State: *
Zip Code: *	-
Phone Number: *	example: (999)999-9999
Work Number:	Extension: example:(999)999-9999
Cell Phone:	example: (999)999-9999
E-mail:
Preparer's Name:
Preparer's E-mail:
Preferred Number: *	Preferred Time:

Type of claim being reported *
Automobile accident Farmowner claim General liability	Homeowner claim Commercial property claim

Policy Information
Policy Number: *

Date of accident/loss: *	example: mm/dd/yyyy


Brief Description of Loss



Disclaimer: Completing this form does not guarantee coverage. Coverage will be determined based on the status of your account and the coverage you purchased. Your agent will be able to explain your coverage and answer any questions about your claim.