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Submit An Auto Claim

Contact Information...
Name (required)
Address
Address (second line)
City
State
Zip

Please Contact Me Via...
Phone E-Mail Fax
Work Phone
Best Time To Call
Home Phone
Best Time To Call
Fax
E-Mail (required)

Policyholder Information
Policy Number
 
Check this box if Policyholder Name/Telephone Number matches "Contact Information".
If you checked the box above, please skip to "Accident Information",
otherwise complete the questions in this shaded area.
Policyholder Name
Daytime Phone
Policyholder - Address
Address (line 2)
Policyholder - City
Policyholder - State   Zip

Accident Information
Date of Accident / / mm / dd / yyyy
Time of Accident
hh:mm     AM PM
 
Check this box if Accident Location matches Policyholder Address.
If you checked the box above, please skip to "Brief Description of Accident",
otherwise complete the questions in this shaded area.
Accident Location - Address
Accident Location - City
Accident Location - State   Zip 
Brief Description of Accident
Police/Fire Contacted? Yes No
Police/Fire Report Number
Police/Fire Department Name
Any Witnesses Present? Yes No
Did Injuries Result From Accident? Yes No
If there WERE injuries, please provide
Name, Address, Phone Number and Extent of the Injuries in the box below.
 

Damage Information
Was Policyholder Vehicle Damaged? Yes No
If Policyholder Vehicle WAS Damaged,
complete the questions in this shaded area.
Vehicle Year
Vehicle Make
Vehicle Model (e.g., Civic, Taurus, Sentra ...)
Describe the Damage to the Vehicle

 
Where can the vehicle be seen? (give address or phone # if known)

 
Describe Damage to Other Vehicles

Describe Damage to Other Property (if applicable)

Other Involved Parties
Provide Contact and Vehicle information
for ALL parties involved in the accident.

 

Fraud Warning

   Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil penalties and criminal prosecution for insurance fraud. 




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