Submit a Claim

Name of Contact:
*  
Name of Insured:
Contact Telephone:
*  
Contact Email:
Date of Claim:
Time of Claim:
Location of Claim:
Insurance Company:
Insurance Type:
Type of Claim:

Brief Description of Claim:

Other People Involved and their Contact Information:

List Authorities that were Called:

Any Other Pertinent Comments:

After submitting this form, we will contact you as soon as possible.

   

Please note this is an alternative method for communicating with us. If you have any questions or need immediate help with your claim please give us a call.

 


info-wdi@leavitt.com

816 5th Street
PO Box 1300
Rapid City, SD 57709
Phone: 605.342.3130

1001 Lazelle Ave
PO Box 490
Sturgis, SD 57785
Phone: 605.347.4583

2011 N. Main
PO Box 98
Spearfish, SD 57783
Phone: 605.642.2624

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