Emergency Contact Form

To help prevent and resolve disasters, we have created our Emergency Contact Program. In case of an emergency, we want to be able to reach you quickly. But, what if we can’t get a hold of you? We can call your Emergency Contact. Or, what if your Emergency Contact becomes aware of an urgent matter concerning you, your family, or your property? They can contact us for immediate assistance and help prevent your situation from getting worse.

Here are a few examples:

  • A mother and two young children were in a car accident. The two children were unharmed but the mother was unconscious. The police found our card in her wallet and called our office. We then called her Emergency Contact, an aunt, who immediately went to the hospital to be with the children.
  • A client’s home was badly damaged in a fire while they were on vacation. Their neighbor was their Emergency Contact and called us. We got the claim started immediately and the windows were boarded up before five o’clock that evening.

Please take a moment and fill out this form with the names of one or more relatives, neighbors, friends, or colleagues who can serve as your Emergency Contact. Their name and information will be kept confidential and we will not solicit them as clients.

Your Name(Required)

Emergency Contact #1


Emergency Contact #2


Emergency Contact #3


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