Online Claims Form If you would like to speak with a Van Wagner Representative, call 800-735-1588. Policy Holder Information Policy Holder Name Policy NumberAHM- Contact Name Contact Phone Contact Email * Add another contact Incident Information Claimant Name (If known) Incident Type: Please select... Lawsuit Records request Subpeona Medical Payments Malpractice Bodily Injury Property Damage Other How were you notified? Please select... Lawyer letter Subpoena Phone Call Fax Email Other Describe Other: Other (Describe): When were you notified? When did this happen (If known) Summons Received? YesNo Please attach a copy (if available) Describe the incident and situation in detail: Attach any documentation you have received regarding this incident: Attach another file Please write anything else you would like the claims representative to know: Need assistance with this form?