Ackley-Peters-Haubert Insurance

As a service for our customers we are happy to offer you the convenience of submitting your claim information via the internet. Please fill out the following form AS COMPLETELY AS POSSIBLE. The more detailed your answers, the faster we can process your information and settle your claim.

Name
Organization
Street address
Address (cont.)
City
State
Zip/Postal code
Work Phone
Home Phone
FAX
E-mail

Enter the date of loss	-- mm/dd/yy
Brief Description of Loss
What is the type of Loss:	Home Auto Boat Other
Were any people injured?	Yes No Not Applicable
If auto claim, is the car driveable?	Yes No Not Applicable
Was incident reported to the police?	Yes No Not Applicable
Policy number	(Optional)
Driver Name
Vehicle type
Year of vehicle
Vehicle Make
Vehicle Model
Location of Loss (ie. state, street)
Additional Information
IF YOU DO NOT HEAR FROM US WITHIN 48 HOURS, PLEASE CALL 517-663-2651 or 1-800-334-6157.