This form is for our insured members only.  If you wish to file a claim against one of our insured members, please submit your claim in writing directly to the county, city or other special purpose district.  If you need further instructions on filing a claim, please visit the State of Idaho's website for Idaho Code Statutes.

Your name:

Your Phone:    Your E-mail:

Name of Your Entity:

Your Affiliation/Title:

Address:

Check here if you are the primary contact for this form.
Contact Person:

Contact's Phone:    Contact's E-mail:

Contact's Affiliation:

Date Claim Occurred:

Details of Claim:

Employees Involved:

Name of Person filing claim against your Entity?

Date Person Filed Claim against Your Entity:

Make, Model & VIN of Your Vehicle: