If you need immediate assistance, please call: (800) 315-6090
Email new claim assignments to:
reportaclaim@narisk.com
Fax: (866) 261-8507
Begin
Policy
Claim
Ins Vehicle
Other Vehicle
Other Parties
Finish
Begin The Claim
*
Your First Name
*
Your Last Name
*
Your Address
*
Your City
*
Your State
*
Your Zip
Your Home Phone
Your Work Phone
Your Extension
Your Cell Phone
Your Email
(A copy of this Web Reported Claim will be sent to the above e-mail address.)
*
Date of Loss
Approximate Time of Loss
Are you a party to the claim?
Yes
No
What is your relationship to the claim?
Employer
Policyholder
Claimant
Attorney
Agent
Other
Policyholder
*
Company Name
*
First Name
*
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
Preferred Contact
Home Phone
Work Phone
Cell Phone
E-mail
SMS Text
Other
Other
Policy #
Was the Policyholder involved in the accident?
Yes
No
Was anyone injured?
Yes
No
Was there damage to property other than the Policyholder's?
Yes
No
Claim Details
*
Address or Intersection of Accident
*
City
*
State
Zip
Briefly describe what happened in the incident
Were local authorities notified or on the scene?
Yes
No
Agency Name/Precinct
Report Number
Officer/Authority Name
Badge Number
Was anyone cited for the accident?
Yes
No
Who was cited?
What was the citation for?
How many vehicles were involved?
Policyholder Vehicle Information
Vehicle Type
VIN
*
Year
*
Make
*
Model
Color
License Plate#
State
Is the vehicle drivable?
Yes
No
Describe damage to vehicle
Where is the vehicle now?
Owner of Vehicle
Click here if Policyholder
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
Was owner in the vehicle at time of accident?
Yes
No
Driver of Vehicle
Click here if Policyholder
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
Was the driver injured in the accident?
Yes
No
Describe the driver's injury
Other Vehicle Information
Vehicle Type
VIN
*
Year
*
Make
*
Model
Color
License Plate#
State
Is the vehicle drivable?
Yes
No
Describe damage to vehicle
Where is the vehicle now?
Owner of Other Vehicle
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
Was owner in the vehicle at time of accident?
Yes
No
Driver of Other Vehicle
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
Was the driver injured in the accident?
Yes
No
Describe the driver's injury
Other Parties Involved
Other Party #1
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
How were they involved?
Passenger
Witness
Owner
Attorney
Employer
In relation to what Vehicle?
Policyholder Vehicle
Vehicle 2
Vehicle 3
Was this person injured?
Yes
No
If yes, please describe the injuries
Other Party #2
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
Home Phone
Work Phone
Extension
Cell Phone
Email
How were they involved?
Passenger
Witness
Owner
Attorney
Employer
In relation to what Vehicle?
Policyholder Vehicle
Vehicle 2
Vehicle 3
Was this person injured?
Yes
No
If yes, please describe the injuries
Summary
Is there anything else that you would like to note?
Attachments
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