www.staging.millersmutualgroup.com
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23.238.34.8
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Submitted URL: https://staging.millersmutualgroup.com/
Effective URL: https://www.staging.millersmutualgroup.com/
Submission: On December 06 via api from US — Scanned from DE
Effective URL: https://www.staging.millersmutualgroup.com/
Submission: On December 06 via api from US — Scanned from DE
Form analysis 5 forms found in the DOM
GET https://www.staging.millersmutualgroup.com
<form class="d-inline-block top-search-mobile position-absolute top-0" action="https://www.staging.millersmutualgroup.com" method="get" id="header-search-form" style="width:calc(100% - 1.5rem);z-index:-1;opacity:0;">
<div class="input-group position-relative">
<input type="text" class="top-search-field form-control rounded-corners border-info bg-white text-dark border-0 shadow" placeholder="What can we help you with?" aria-label="Search" name="s" value="" aria-describedby="search-button">
<button class="top-searchbtn-mobile rounded-circle position-absolute d-flex align-items-center p-0 border-0 bg-transparent" type="submit" aria-label="Search" id="search-button" style="right:25px;top:25px;height:22.41px;width:22.41px;">
<img alt="Close search form" data-src="https://www.millersmutualgroup.com/wp-content/uploads/2023/03/Icon-feather-search-over.svg" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload">
</button>
</div>
</form>GET https://www.staging.millersmutualgroup.com
<form class="d-inline-block top-search position-absolute" action="https://www.staging.millersmutualgroup.com" method="get" id="header-search-form" style="z-index: -1; top: 25px; right: 159.906px;">
<div class="input-group position-relative">
<input style="width: 22px; height: 32px;" type="text" class="top-search-field form-control rounded-pill border-info bg-white text-dark" placeholder="What can we help you with?" aria-label="Search" name="s" value=""
aria-describedby="search-button">
<button class="top-searchbtn rounded-circle position-absolute d-flex align-items-center p-0 border-0 bg-transparent" type="submit" aria-label="Search" id="search-button" style="right:5px;top:5px;height:22.41px;width:22.41px;"><img
alt="Close search form" data-src="https://www.millersmutualgroup.com/wp-content/uploads/2023/03/Icon-feather-search-over.svg" src="https://www.millersmutualgroup.com/wp-content/uploads/2023/03/Icon-feather-search-over.svg"
class=" lazyloaded"> </button>
</div>
</form>POST /#gf_2
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2" action="/#gf_2" data-formid="2" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_2_3"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_3"><span class="tfs-16 position-relative" style="top:12px;">*Required</span></div>
<div id="field_2_1" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_2_1"><label
class="gfield_label gform-field-label" for="input_2_1">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_1" id="input_2_1" type="text" value="" class="large" tabindex="49" placeholder="First Name Last Name*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_4" class="gfield gfield--type-phone gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_4"><label class="gfield_label gform-field-label" for="input_2_4">Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_2_4" type="tel" value="" class="large" tabindex="50" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_5" class="gfield gfield--type-email gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_5"><label class="gfield_label gform-field-label" for="input_2_5">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_5" id="input_2_5" type="email" value="" class="large" tabindex="51" placeholder="Email Address*" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_2_6" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_6"><label class="gfield_label gform-field-label" for="input_2_6">Best time to contact<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_6" id="input_2_6" class="large gfield_select" tabindex="52" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Best Time to Contact You*</option>
<option value="Morning">Morning</option>
<option value="Afternoon">Afternoon</option>
<option value="Evening">Evening</option>
</select></div>
</div>
<div id="field_2_7" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_7"><label class="gfield_label gform-field-label" for="input_2_7">Name of Insured<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_2_7" type="text" value="" class="large" tabindex="53" placeholder="Name of Insured (displayed on policy documents)*" aria-required="true"
aria-invalid="false"></div>
</div>
<div id="field_2_8" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_8"><label class="gfield_label gform-field-label" for="input_2_8">Policy Number<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_2_8" type="text" value="" class="large" tabindex="54" placeholder="Policy Number (example: AAA 1234567 01)*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_9"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full w-100 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_9"><label class="gfield_label gform-field-label" for="input_2_9">Date of Loss<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_2_9" type="text" value="" class="datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon hasDatepicker initialized" tabindex="55" placeholder="Date of Loss*"
aria-describedby="input_2_9_date_format" aria-invalid="false" aria-required="true">
<span id="input_2_9_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_2_9" class="gform_hidden" value="https://www.staging.millersmutualgroup.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_2_10"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_10">
<p class="tfs-21 text-primary mt-3 fw-bold mb-0 pb-0">Preferred Person to Contact About This Claim:</p>
</div>
<div id="field_2_17" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_17"><label class="gfield_label gform-field-label" for="input_2_17">Contact Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_2_17" type="text" value="" class="large" tabindex="56" placeholder="First Name Last Name*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_18" class="gfield gfield--type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_18"><label class="gfield_label gform-field-label" for="input_2_18">Contact Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_18" id="input_2_18" type="text" value="" class="large" tabindex="57" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_19" class="gfield gfield--type-email gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_19"><label class="gfield_label gform-field-label" for="input_2_19">Contact Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_19" id="input_2_19" type="email" value="" class="large" tabindex="58" placeholder="Contact Email*" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_2_20"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_20">
<p class="tfs-21 mt-3 text-primary fw-bold mb-0 pb-0">Location of Loss:</p>
</div>
<div id="field_2_11" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_11"><label class="gfield_label gform-field-label" for="input_2_11">Street Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_11" id="input_2_11" type="text" value="" class="large" tabindex="59" placeholder="Street Address*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_12" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_2_12"><label
class="gfield_label gform-field-label" for="input_2_12">Address 2</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_2_12" type="text" value="" class="large" tabindex="60" placeholder="Address Line 2*" aria-invalid="false"></div>
</div>
<div id="field_2_13" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_13"><label class="gfield_label gform-field-label" for="input_2_13">City<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_2_13" type="text" value="" class="large" tabindex="61" placeholder="City*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_14" class="gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_14"><label class="gfield_label gform-field-label" for="input_2_14">State<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_14" id="input_2_14" class="large gfield_select" tabindex="62" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">State*</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select></div>
</div>
<div id="field_2_15" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_2_15"><label class="gfield_label gform-field-label" for="input_2_15">Zip<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_2_15" type="text" value="" class="large" tabindex="63" placeholder="Zip Code*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_16"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_16">
<p class="tfs-21 mt-3 text-primary fw-bold mb-0 pb-0">Description of Loss (Type of property damage, injuries, etc.)</p>
</div>
<div id="field_2_21" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_2_21"><label
class="gfield_label gform-field-label" for="input_2_21">Additional Comments</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_21" id="input_2_21" class="textarea large" tabindex="64" placeholder="Additional Comments" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform-footer gform_footer top_label"> <input type="submit" id="gform_submit_button_2" class="gform_button button" onclick="gform.submission.handleButtonClick(this)" value="Submit" tabindex="65"> <input type="hidden" name="gform_ajax"
value="form_id=2&title=&description=&tabindex=49&theme=gravity-theme">
<input type="hidden" class="gform_hidden" name="gform_submission_method" data-js="gform_submission_method_2" value="iframe">
<input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="2">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_2"
value="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">
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="0">
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;" class="akismet-fields-container" data-prefix="ak_"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js"
value="1733450536415">
<script src="data:text/javascript;base64,ZG9jdW1lbnQuZ2V0RWxlbWVudEJ5SWQoImFrX2pzXzEiKS5zZXRBdHRyaWJ1dGUoInZhbHVlIiwobmV3IERhdGUoKSkuZ2V0VGltZSgpKQ==" defer=""></script>
</p>
</form>POST /#gf_3
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_3" id="gform_3" action="/#gf_3" data-formid="3" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_3" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_3_3"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_3"><span class="tfs-16 position-relative" style="top:12px;">*Required</span></div>
<div id="field_3_1" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_3_1"><label
class="gfield_label gform-field-label" for="input_3_1">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_1" id="input_3_1" type="text" value="" class="large" tabindex="49" placeholder="First Name Last Name*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_4" class="gfield gfield--type-phone gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_4"><label class="gfield_label gform-field-label" for="input_3_4">Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_3_4" type="tel" value="" class="large" tabindex="50" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_5" class="gfield gfield--type-email gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_5"><label class="gfield_label gform-field-label" for="input_3_5">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_5" id="input_3_5" type="email" value="" class="large" tabindex="51" placeholder="Email Address*" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_3_6" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_6"><label class="gfield_label gform-field-label" for="input_3_6">Best time to contact<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_6" id="input_3_6" class="large gfield_select" tabindex="52" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Best Time to Contact You*</option>
<option value="Morning">Morning</option>
<option value="Afternoon">Afternoon</option>
<option value="Evening">Evening</option>
</select></div>
</div>
<div id="field_3_7" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_7"><label class="gfield_label gform-field-label" for="input_3_7">Name of Insured<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_3_7" type="text" value="" class="large" tabindex="53" placeholder="Name of Insured (displayed on policy documents)*" aria-required="true"
aria-invalid="false"></div>
</div>
<div id="field_3_8" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_8"><label class="gfield_label gform-field-label" for="input_3_8">Policy Number<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_3_8" type="text" value="" class="large" tabindex="54" placeholder="Policy Number (example: AAA 1234567 01)*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_9"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full w-100 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_9"><label class="gfield_label gform-field-label" for="input_3_9">Date of Loss<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_3_9" type="text" value="" class="datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon hasDatepicker initialized" tabindex="55" placeholder="Date of Loss*"
aria-describedby="input_3_9_date_format" aria-invalid="false" aria-required="true">
<span id="input_3_9_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_9" class="gform_hidden" value="https://www.staging.millersmutualgroup.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_10"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_10">
<p class="tfs-21 text-primary mt-3 fw-bold mb-0 pb-0">Preferred Person to Contact About This Claim:</p>
</div>
<div id="field_3_17" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_17"><label class="gfield_label gform-field-label" for="input_3_17">Contact Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_3_17" type="text" value="" class="large" tabindex="56" placeholder="First Name Last Name*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_18" class="gfield gfield--type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_18"><label class="gfield_label gform-field-label" for="input_3_18">Contact Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_18" id="input_3_18" type="text" value="" class="large" tabindex="57" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_19" class="gfield gfield--type-email gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_19"><label class="gfield_label gform-field-label" for="input_3_19">Contact Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_19" id="input_3_19" type="email" value="" class="large" tabindex="58" placeholder="Contact Email*" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_3_16"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_16">
<p class="tfs-21 mt-3 text-primary fw-bold mb-0 pb-0">Description of Loss (Type of property damage, injuries, etc.)</p>
</div>
<div id="field_3_11" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_11"><label class="gfield_label gform-field-label" for="input_3_11">Street Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_11" id="input_3_11" type="text" value="" class="large" tabindex="59" placeholder="Street Address*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_12" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_3_12"><label
class="gfield_label gform-field-label" for="input_3_12">Address 2</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_3_12" type="text" value="" class="large" tabindex="60" placeholder="Address Line 2*" aria-invalid="false"></div>
</div>
<div id="field_3_13" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_13"><label class="gfield_label gform-field-label" for="input_3_13">City<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_3_13" type="text" value="" class="large" tabindex="61" placeholder="City*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_14" class="gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_14"><label class="gfield_label gform-field-label" for="input_3_14">State<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_14" id="input_3_14" class="large gfield_select" tabindex="62" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">State*</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select></div>
</div>
<div id="field_3_15" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_15"><label class="gfield_label gform-field-label" for="input_3_15">Zip<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_3_15" type="text" value="" class="large" tabindex="63" placeholder="Zip Code*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_3_20"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_20">
<p class="tfs-21 mt-3 text-primary fw-bold mb-0 pb-0">Location of Loss:</p>
</div>
<div id="field_3_21" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_3_21"><label
class="gfield_label gform-field-label" for="input_3_21">Additional Comments</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_21" id="input_3_21" class="textarea large" tabindex="64" placeholder="Additional Comments" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform-footer gform_footer top_label"> <input type="submit" id="gform_submit_button_3" class="gform_button button" onclick="gform.submission.handleButtonClick(this)" value="Submit" tabindex="65"> <input type="hidden" name="gform_ajax"
value="form_id=3&title=&description=&tabindex=49&theme=gravity-theme">
<input type="hidden" class="gform_hidden" name="gform_submission_method" data-js="gform_submission_method_3" value="iframe">
<input type="hidden" class="gform_hidden" name="is_submit_3" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="3">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_3"
value="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">
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_target_page_number_3" id="gform_target_page_number_3" value="0">
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_source_page_number_3" id="gform_source_page_number_3" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;" class="akismet-fields-container" data-prefix="ak_"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_2" name="ak_js"
value="1733450536415">
<script src="data:text/javascript;base64,ZG9jdW1lbnQuZ2V0RWxlbWVudEJ5SWQoImFrX2pzXzIiKS5zZXRBdHRyaWJ1dGUoInZhbHVlIiwobmV3IERhdGUoKSkuZ2V0VGltZSgpKQ==" defer=""></script>
</p>
</form>POST /#gf_4
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_4" id="gform_4" action="/#gf_4" data-formid="4" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_4" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_4_3"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_3"><span class="tfs-16 position-relative" style="top:12px;">*Required</span></div>
<div id="field_4_1" class="gfield gfield--type-text gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_1"><label class="gfield_label gform-field-label" for="input_4_1">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_1" id="input_4_1" type="text" value="" class="large" tabindex="49" placeholder="First Name Last Name*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_22" class="gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_4_22">
<label class="gfield_label gform-field-label" for="input_4_22">Agency Name</label>
<div class="ginput_container ginput_container_text"><input name="input_22" id="input_4_22" type="text" value="" class="large" tabindex="50" placeholder="Agency Name" aria-invalid="false"></div>
</div>
<div id="field_4_4" class="gfield gfield--type-phone gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_4"><label class="gfield_label gform-field-label" for="input_4_4">Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_4_4" type="tel" value="" class="large" tabindex="51" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_5" class="gfield gfield--type-email gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_5"><label class="gfield_label gform-field-label" for="input_4_5">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_5" id="input_4_5" type="email" value="" class="large" tabindex="52" placeholder="Email Address*" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_4_6" class="gfield gfield--type-select gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_6"><label class="gfield_label gform-field-label" for="input_4_6">Best time to contact<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_6" id="input_4_6" class="large gfield_select" tabindex="53" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Best Time to Contact You*</option>
<option value="Morning">Morning</option>
<option value="Afternoon">Afternoon</option>
<option value="Evening">Evening</option>
</select></div>
</div>
<div id="field_4_23" class="gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_4_23">
<label class="gfield_label gform-field-label" for="input_4_23">Agency Website</label>
<div class="ginput_container ginput_container_text"><input name="input_23" id="input_4_23" type="text" value="" class="large" tabindex="54" placeholder="Agency Website Address" aria-invalid="false"></div>
</div>
<div id="field_4_16"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_16">
<p class="tfs-21 mt-3 text-primary fw-bold mb-0 pb-0">Agency Address:</p>
</div>
<div id="field_4_11" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_11"><label class="gfield_label gform-field-label" for="input_4_11">Agency Street Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_11" id="input_4_11" type="text" value="" class="large" tabindex="55" placeholder="Street Address*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_12" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_4_12"><label
class="gfield_label gform-field-label" for="input_4_12">Agency Address 2</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_4_12" type="text" value="" class="large" tabindex="56" placeholder="Address Line 2*" aria-invalid="false"></div>
</div>
<div id="field_4_13" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_13"><label class="gfield_label gform-field-label" for="input_4_13">Agency City<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_4_13" type="text" value="" class="large" tabindex="57" placeholder="City*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_14" class="gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_14"><label class="gfield_label gform-field-label" for="input_4_14">Agency State<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_14" id="input_4_14" class="large gfield_select" tabindex="58" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">State*</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select></div>
</div>
<div id="field_4_15" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_4_15"><label class="gfield_label gform-field-label" for="input_4_15">Agency Zip<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_4_15" type="text" value="" class="large" tabindex="59" placeholder="Zip Code*" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_25"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_25">
<p> </p>
</div>
<div id="field_4_24" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_4_24"><label
class="gfield_label gform-field-label" for="input_4_24">How Did You Hear About Us?</label>
<div class="ginput_container ginput_container_text"><input name="input_24" id="input_4_24" type="text" value="" class="large" tabindex="60" placeholder="How Did You Hear About Us?" aria-invalid="false"></div>
</div>
<div id="field_4_21" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_4_21"><label
class="gfield_label gform-field-label" for="input_4_21">Additional Comments</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_21" id="input_4_21" class="textarea large" tabindex="61" placeholder="Additional Comments" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform-footer gform_footer top_label"> <input type="submit" id="gform_submit_button_4" class="gform_button button" onclick="gform.submission.handleButtonClick(this)" value="Submit" tabindex="62"> <input type="hidden" name="gform_ajax"
value="form_id=4&title=&description=&tabindex=49&theme=gravity-theme">
<input type="hidden" class="gform_hidden" name="gform_submission_method" data-js="gform_submission_method_4" value="iframe">
<input type="hidden" class="gform_hidden" name="is_submit_4" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="4">
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* Find an Agent * Make a Payment * Report a Claim * Agent Portal * Agent Login * Login Instructions * Reset Password * Contact Us * Skip to content * Insurance Solutions * Apartment Buildings * Commercial Real Estate * Dwellings * Learn * Best Practices * Blog * Billing & Claim FAQs * Claim Center * Claims Process * Report a Claim * For Agents * Become an Agent * Insurance Products * Riverside Brokerage * Social Media Library * Toolkits * Our Story * About Us * Careers * Community Involvement * Contact Us * Meet Our Team * Review Us * Insurance Solutions * Apartment Buildings * Commercial Real Estate * Dwellings * Learn * Best Practices * Blog * Billing & Claim FAQs * Claim Center * Claims Process * Report a Claim * For Agents * Become an Agent * Insurance Products * Riverside Brokerage * Social Media Library * Toolkits * Our Story * About Us * Careers * Community Involvement * Contact Us * Meet Our Team * Review Us -------------------------------------------------------------------------------- * Find an Agent * Make a Payment * Report a Claim * Agent Portal * Agent Login * Login Instructions * Reset Password * Contact Us * YOUR PROPERTY. OUR SPECIALTY. Choose an insurance partner that understands the unique risks in your industry – and how to protect against them. Why Millers Mutual STUDENT HOUSING PROTECTION, SIMPLIFIED Discover diverse insurance options for off-campus, student housing properties. See Solutions Previous Next BE CONFIDENT IN YOUR POLICY Unlike other insurers, Millers Mutual is hyper-focused on the multifamily housing industry and the complex risks that property owners face. Because of our singular focus, you can expect unmatched expertise, thorough coverage, and a partner that comes through when it really counts. PROPERTIES WE COVER Whether you own one rental property or a whole portfolio, we can help. Get smart coverage options for a wide range of multifamily housing, student housing, affordable housing, and commercial properties. Dwellings Apartment Buildings Commercial Real Estate SMART COVERAGE FOR RENTAL DWELLINGS We cover rental dwellings of one to four units, including row homes. See Solutions RIGHT COVERAGE FOR APARTMENT BUILDINGS We cover garden-style apartments, senior independent living properties, and apartment buildings up to four stories and up to $5 million in value. See Solutions KEEP YOUR COMMERCIAL REAL ESTATE PROTECTED We cover a variety of commercial and mixed-use real estate up to four stories and up to $5 million in value. See Solutions PROPERTIES WE COVER Dwellings SMART COVERAGE FOR RENTAL DWELLINGS We cover rental dwellings of one to four units, including row homes. See Solutions Apartment Buildings RIGHT COVERAGE FOR APARTMENT BUILDINGS We cover garden-style apartments, senior independent living properties, and apartment buildings up to four stories and up to $5 million in value. See Solutions Commercial Real Estate KEEP YOUR COMMERCIAL REAL ESTATE PROTECTED We cover a variety of commercial and mixed-use real estate up to four stories and up to $5 million in value. See Solutions PROTECT YOUR INVESTMENT – AND YOUR BOTTOM LINE It’s more than a property. It’s your livelihood. We get it, so our coverage solutions are tailored to the specific risks you face, including: Fire and water damage Natural disasters Theft and vandalism Injuries and lawsuits Business risks TRUSTED BY YOUR INDUSTRY Millers Mutual provides quick claim resolution, courteous service, and affordable pricing. Fair insurance coverage and rates are difficult to obtain for affordable housing, but Millers Mutual never hesitates to provide us just that. Sharlene Woodruff CFO, HDC MidAtlantic Our business is based on two words: Quality and Honesty. We have identified that same commitment from Millers Mutual, and appreciate their high-quality service and support. Phil Noto President, Santisi Imports, LTD It’s very, very important for an investor to have an insurance partner, and that’s what I call Millers Mutual. Mike Serluco Owner, Consolidated Properties, Inc. Millers Mutual provides quick claim resolution, courteous service, and affordable pricing. Fair insurance coverage and rates are difficult to obtain for affordable housing, but Millers Mutual never hesitates to provide us just that. Sharlene Woodruff CFO, HDC MidAtlantic Our business is based on two words: Quality and Honesty. We have identified that same commitment from Millers Mutual, and appreciate their high-quality service and support. Phil Noto President, Santisi Imports, LTD It’s very, very important for an investor to have an insurance partner, and that’s what I call Millers Mutual. Mike Serluco Owner, Consolidated Properties, Inc. Previous Next YOUR QUESTIONS, ANSWERED What should you consider when buying landlord insurance or apartment building insurance? How can you minimize your risk? Get the facts at our Education Center. View Best Practices LATEST INSIGHTS Millers News December 3, 2024 Tim Kirk To Retire After More Than 40 Years in the Insurance Industry Read More Education December 2, 2024 How Cooling Inflation Can Impact Landlords Read More Charitable Giving November 5, 2024 Millers Mutual Exceeds 2024 United Way Campaign Goals Read More LATEST INSIGHTS Millers News December 3, 2024 Tim Kirk To Retire After More Than 40 Years in the Insurance Industry Read More Education December 2, 2024 How Cooling Inflation Can Impact Landlords Read More Charitable Giving November 5, 2024 Millers Mutual Exceeds 2024 United Way Campaign Goals Read More Previous Next Millers Mutual is now appointing new agents in North Carolina. Become an Agent Through our network of independent agents, we offer rental property insurance and commercial insurance to customers in Pennsylvania, Delaware, Maryland, North Carolina, Ohio, Virginia, and Washington, D.C. * Contact Us * 3815 TecPort Drive Suite 200 Harrisburg, PA 17111 * 800-745-4555 * Email Us * Follow Us * * * Site Map * Privacy Notice * Disclaimer * Accessibility Statement * Follow Us * * * Contact Us * 3815 TecPort Drive Suite 200 Harrisburg, PA 17111 * 800-745-4555 * Email Us * Site Map * Privacy Notice * Disclaimer * Accessibility Statement © 2024 Millers Mutual Insurance. All rights reserved. © 2024 Millers Mutual Insurance. © 2024 Millers Mutual Insurance. REPORT A CLAIM Use the form below to report a claim under your rental property insurance policy. Please DO NOT include sensitive information, like your financial information or password. *Required Name(Required) Phone(Required) Email(Required) Best time to contact(Required) Best Time to Contact You*MorningAfternoonEvening Name of Insured(Required) Policy Number(Required) Date of Loss(Required) MM slash DD slash YYYY Preferred Person to Contact About This Claim: Contact Name(Required) Contact Phone(Required) Contact Email(Required) Location of Loss: Street Address(Required) Address 2 City(Required) State(Required) State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip(Required) Description of Loss (Type of property damage, injuries, etc.) Additional Comments Δ TRACK A CLAIM Use the form below to track a claim under your rental property insurance policy. Please DO NOT include sensitive information, like your financial information or password. *Required Name(Required) Phone(Required) Email(Required) Best time to contact(Required) Best Time to Contact You*MorningAfternoonEvening Name of Insured(Required) Policy Number(Required) Date of Loss(Required) MM slash DD slash YYYY Preferred Person to Contact About This Claim: Contact Name(Required) Contact Phone(Required) Contact Email(Required) Description of Loss (Type of property damage, injuries, etc.) Street Address(Required) Address 2 City(Required) State(Required) State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip(Required) Location of Loss: Additional Comments Δ REQUEST AN APPOINTMENT In the aftermath of the unforeseen, clients only want to hear one thing from their agent: “You’re covered.” Millers Mutual is the carrier that turns a client’s call full of dread into a moment of relief. If you’re an independent agent located in Delaware, the District of Columbia, Maryland, North Carolina, Ohio, Pennsylvania, or Virginia and want to learn more about becoming a Millers Mutual agent – or accessing our products through our in-house brokerage – please use the form below or call 717-963-8566 to speak with Stuart Cohen, our relationship leader. If you’re an independent agent located in Delaware, the District of Columbia, Maryland, North Carolina, Ohio, Pennsylvania, or Virginia and want to *Required Name(Required) Agency Name Phone(Required) Email(Required) Best time to contact(Required) Best Time to Contact You*MorningAfternoonEvening Agency Website Agency Address: Agency Street Address(Required) Agency Address 2 Agency City(Required) Agency State(Required) State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Agency Zip(Required) How Did You Hear About Us? 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