Online Claims Form Van Wagner Group Claims Form If you would like to speak with a Van Wagner Representative, please call 1-800-735-1588. Policy Holder Information Policy Holder Name Policy Number AHM- Contact Contact Name Contact Phone Contact Email Incident Information Claimant Name (If Known) Incident TypePlease select... Lawsuit Records Request Subpoena Medical Payments Malpractice Bodily Injury Property Damage Other How were you notified?Please select... Lawyer Letter Subpoena Phone Call Fax Email Other Other Incident (Describe) Other Notification (Describe) When were you notified? When did this happen (If Known)? Summons Received?YesNo Attach Copy of Summons (If Available) Describe the incident and situation in detail Attach any documentation you have received regarding this incident Additional Information Please add anything else you would like the claims representative to know below Need assistance with this form?