Webb Young Webb Liles Tolentino
3007 NW 63 Ste 130
Oklahoma City, Oklahoma 73116

Phone: 405-843-9481
Fax: 405-848-8417

Email Us

Claim Form
	First & Last Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
Date of Loss:		Time of Loss:
Location of Incident/Loss:
Description of Incident/Loss:
Were the authorities called:
	Additional Information that might help expedite the claim process:
By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim. Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

Enter the text from the box:

click for new code