Auto Claim

Contact Information

*Last Name
*First Name
Contact Phone
*Email Address
Address (optional)
Policy Number:
Name of Insurance Company on Policy

Vehicle Involved

Vehicle Year
Vehicle Make
Vehicle Model

Loss General

Date of Loss
Cause of Damage
Estimated Damage

The following section is applicable to Accident only

Driver First Name
Driver Last Name
Relationship to Applicant
Time of Accident
Number of Cars Involved
Police Notified
YesNo
Estimated Percentage at Fault

Location of the Accident

Street/Highway
City/Town
State
Short Description

Other Party Information (if available)

Other Driver Name
Address
Home Phone
Work Phone
Driver's License
License Plate
License State
Insurance Company
Policy Number
Vehicle Year/Make/Model
Damage Description

The following sections is applicable to Theft only

Time Loss Discovered
Date Police Notified
Vehicle Recovered
YesNo
Date Vehicle Recovered
Short Description

I understand that any person who files a claim with the intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

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