REsources & Tools

MIIA Claims Reporting

If you are a MIIA member submitting a claim, please complete the form below.

Property, Liability, or Automobile Loss Notice
*Member Community/District:
*Member contact person:
*Member contact e-mail address:
*Contact phone number (area code first):	--ext:
*Date of incident:
Description of Incident: Please do not include sensitive subscriber information, such as Social Security Numbers in this form. This form can be viewed by a third party while in transit.
Location of incident:
Full name of person presenting claim:
Claimant phone number (area code first):	--ext:
Claimant address (line 1):
Address (line 2):
Claimant city:	State: Zip code:
Type of vehicle involved (if applicable):
Community/District department involved:
General comments: Please do not include sensitive subscriber information, such as Social Security Numbers in this form. This form can be viewed by a third party while in transit.

*Items with an asterisk(*) are required fields.