File an Auto Claim

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1 Step 1
2 Step 2
3 Step 3
4 Step 4
5 Step 5
6 Step 6
7 Step 7
Auto Claim
Basic Info | Page 1 of 7
Policy Number
Effective Datemm/dd/yyy
Expiration Datemm/dd/yyy
Accident Datemm/dd/yyy
Accident Time
Insured | Page 2 of 7
Insured Name
Street Address
Address Line 2optional
City
State
ZIP
Phone Number
Fax Number
SSN or FEIN
Is Contact Person Different from Insured?
Contact Name
Street Address
Address Line 2optional
City
State
ZIP
Phone Number
Fax Number
Loss Details | Page 3 of 7
Location of Accidentinclude city & state
0 /
Authority Contacted
Report Number
Violations/Citations
Description of Accident
0 /
Insured Vehicle | Page 4 of 7
Year
VIN
Make
Model
Plate Number
State
Owner's Name & Address
0 /
Owner's Phone Number
Is Driver Same As Owner
Driver's Name & Address
0 /
Driver's Phone Number
Relation to Insured
Date of Birthmm/dd/yyy
Driver's License Number
State
Purpose of Use
Used with Permission?
Describe Damage
0 /
Estimate Amount
Where Can Vehicle Be Seen?
0 /
Other Insurance on Vehicle
Property Damaged | Page 5 of 7
Vehicle?
Describe Property Damaedif auto, give year, make, model, plate number
0 /
Other Vehicle/Property Insured?
Company/Agency Name
Policy Number
Owner's Name & Address
0 /
Owner's Phone Number
Other Driver's Name & Address
0 /
Other Driver's Phone Number
Describe Damage
0 /
Estimate Amount
Where Can Damage Be Seen?
0 /
Injured | Page 6 of 7
Injured Person's Name
Injured Person's Address
0 /
Injured Person's Phone Number
Was the Injured Person...
Age
Add Injured Person
Injured Person's Name
Injured Person's Address
0 /
Injured Person's Phone Number
Was the Injured Person...
Age
Witnesses or Passengers | Page 7 of 7
List Names and Addresses
0 /
Remarksinclude adjuster asigned
0 /
Reported By
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