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Home > Homeowners > Personal Lines Claim Form
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Personal Lines Claim Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Date of Loss
Time
Location
Injured Party (Name)
Phone#
Address
Email
Property Damaged/Injuries
Description of Incident
Photos/Other Info
Police/Rescue/Fire Dept. report
Report#
Citations
Witnesses: (name/phone)
Record Only?
Reported By
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Tanenbaum Harber of Florida
2900 SW 149th Ave, #100
Miramar, FL 33027-6605

Broward Tel: 954-883-2900
Miami-Dade Tel: 305-620-0200
Jacksonville Tel: 904-807-9121
We've successfully served hundreds of customers and are determined to treat each individual with respect and compassion. Shopping for insurance can be difficult, but our staff does the work for you. Maintain your financial stability and stable coverage by allowing us to help you with your insurance needs.
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