Quick Pay Comp Claim

Please use this submission form for Comp claims less than $3000.

NDIRF Member Name*
Date of Loss*
Year of Vehicle*
Make of Vehicle*
Model of Vehicle*
VIN of Vehicle*
Dollar Amount of Claim*
Loss Type*		Please SelectAnimal collisionAnimal damage other than collisionFalling objectFireFlying missileFreezingGlass damage onlyHailTowingWater damageWeight of ice or snow
Attach estimate/invoice*
Name of person submitting form*
Contact phone number*