File Claim – Surya Insurance Company Inc. RRG

File A Claim:

Please submit your claim request.

Full Name *

What is your relationship to the reported loss? *

Insured
Claimant
Other

Email *

Phone Number *

Date and Time of Loss *

Date

Time

State of Loss *

City of Loss *

Loss Description *

Authority Contacted

Report Number

Date and Time of Report

Date

Time

Your Vehicle Year / Make / Model *

Your Vehicle License Plate *

Your Vehicle VIN

Owner's Name *

Owner's Address

Address Line 1

City

State

Zip Code

Driver's Name *

Driver's Address

Address Line 1

City

State

Zip Code

Driver's Relation to Owner

Driver's Date of Birth

Driver's License Number

Driver's Contact Numbers

Describe Damage *

Est. Amount

Other Vehicle Year / Make / Model

Other Vehicle License Plate

Other Vehicle VIN

Owner of Other Vehicle

Other Vehicle Owner's Address

Address Line 1

City

State

Zip Code

Name of Driver of Other Vehicle

Other Vehicle Driver's License Number

Name of Company Insuring Other Party Against Property Damage

Injured Details

Witness Details

How fast, on what street and in what direction were you traveling?

How fast, on what street and in what direction was the other car traveling?

Please describe the weather conditions

How far away was other car when first noticed?

Number of people in your car

Number of people in other car

Exact point of contact of your car with other car

Exact point of contact of other car with your car

Any Additional Comments / Details

File Upload

Click or drag a file to this area to upload.

Please upload relevant documentation such as police reports, physical damage photo/video etc as a zip file to best facilitate the claims process.

Surya Insurance Company Inc., RRG
608 Fifth Ave Suite #903
New York, NY 10020
Inquiries: info@suryainsrrg.com
Claims: claims@suryainsrrg.com