Auto Claim
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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?
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