EPLI McDonald Claim Form

Required Field

Store #

Once you enter a store # click on another field to enable auto prefill.

Owner/Operator First Name

Owner/Operator Last Name

Policy Number

Phone Number

Insured/Company

Insured/Company's Email Address

Location Street Address

City

State

Zip

This is the person on file to handle claims correspondence.

Person to Contact

Person to Contact Email

Person to Contact Phone

^{If you wish to designate another person to be contacted click below
.}

Add a different contact person

Additional person to handle claims correspondence..

Person to Contact

Person to Contact Email

Person to Contact Phone

Required Field

Claimant's Name

Date you received the Claim or found out about the Potential Claim

If you received a Summons, Complaint, Administrative Agency Charge or similar document, when did you receive it?

REQUIRED: Attach legal document(s)