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Claims Intake Form
We're sorry to hear you've been a victim of an incident requiring you to fill out this form, but we're here to help. Please fill out the information below and we'll begin processing your claim as soon as possible. In the meantime, please take all measures to protect yourself from any further losses.
If you have any questions, please email
[email protected]
Insured Name
*
Broker Name
*
Policy Number
*
Reporting Date
*
Date of incident (the day assets were stolen)
*
Approximate value lost (how much crypto was lost?)
*
Please provide your public key
*
Description of event (what do you think happened?)
*
Upload evidence related to your claim here or you can email them to
[email protected]
. Typical evidence will include police report(s), transaction history, custodian correspondence, etc.
*
Click to choose a file or drag here
Submit
