Loss Run Request Form | UPC Insurance

Use this form to submit your loss run request. Please allow 2 to 3 business days for us to process your request

Requester's name

Requester's email

I am a

I am requesting - Agent/Broker

I am requesting - UPC Associate

Policyholder name

First name

Policy number

Policyholder phone number

Last name

Property address

Street address

City

ZIP/Postal code

Policy date range

Please select the state that the agency is appointed in

Agency name

UPC Agency code

State/Province/Region

Country

If you are not the Agent of Record, you must upload a signed letter from the policyholder

Certify rights

Certify policyholder rights

I certify that I am the policyholder & have full rights to request this policy information

Special instructions/requests