Person Reporting the Claim
First Name
Last Name
Email
Home Phone Number
Work Phone Number
Cell Phone Number
Address (street, city, state, zip)
Year
Make
Model
Driver Name
Is the Vehicle Driveable?
Yes
No
Name, address, and phone number of repair shop or towing company (if applicable)
Policy Holder
Click if same as person reporting claim
First Name
Last Name
Policy Number
Home Phone Number
Work Phone Number
Cell Phone Number
Address (street, city, state, zip)
Year
Make
Model
Driver Name
Is the Vehicle Driveable?
Yes
No
Name, address, and phone number of repair shop or towing company (if applicable)
Other Vehicle Involved in Accident
Year
Make
Model
Driver Name
Is the Vehicle Driveable?
Yes
No
Name, address, and phone number of repair shop or towing company (if applicable)
Accident Information
Date of Accident
Time of Accident
Street or Intersection
City and State
Describe what happened. Be sure to list the names of any witnesses or injured passengers. Also describe any injuries which may have occurred.
Additional Information
Yes
No
Did the police respond?
Policy Agency
Police Report #
Yes
No
Did an ambulance respond?
Yes
No
Were there any injuries?
Yes
No
Were any citations issued?
Yes
No
Were any vehicles towed?
Yes
No
Was weather a factor?
Rain
Hail
Snow
Ice
Other
Yes
No
Do you need a spanish speaking representative?
