Are you a current Marsh McLennan Agency Client? * Yes No

Marsh Client Advisor Name*

Insured Name* *

Contact Name*

Phone Number* *

Zip*

Email *

Description of Loss* Auto Property Other

Relationship to the Client Policy Holder Policy Holder Representative Claimant

Policy Number

Carrier Name

Comments

By filling out this form, I accept that my personal data may be stored and used in accordance with the Marsh McLennan Agency Privacy Notice.