Michigan Millers Insurance -

Claims Hours of Operation

8:00am - 4:30pm, M-F
1-800-888-1914
All other times, 1-877-858-5361

Auto Glass Service
24/7
1-877-858-5361

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Insured Information

Policy Number*

Name*

Street Address*

City*

State*

Zip*

Contact Information

Name*	Email*
Phone* () -	Alternate Phone () -

Loss Description*

Date of Loss*

Claimant Information

Name*

Date of Birth

SSN*

Phone*
() -

Last Day Worked
Claimant is still off Work

Street Address*

City*

State*

Zip*

Type of Injury*

Accident Location

City*

State*

Zip*

Physician or Healthcare Provider