Report New Claim

Please provide us with the information below to report an automobile claim under your policy. The claim process will begin immediately. One of our claims representatives will endeavor to contact the parties involved within 24 business hours. (If this claim has already been properly reported to us in writing, by email or by using the toll-free claim reporting service, you do not need to fill this out).

* required fields are in red

Insured Information
Policy Number (i.e. 01-SSA-111111-11)	--
Name
Home Phone	--
Work Phone	-- Ext.
E-Mail Address

Driver of Insured Vehicle Information
Was the Driver of our Vehicle the same as our Insured?	Yes No Unknown
If no, please provide the following:
Driver's Name
Address
City, State, Zip Code	-
Phone Number	-- Ext.
Relationship to Insured (i.e Mother, Sister, Friend)
Did the Driver Have Permission to Drive Vehicle?	Yes No Unknown
Was Anyone Injured While Riding in Insured Vehicle?	Yes No Unknown
If Yes, Please Give a Description (Include name and extent of injuries)

Policy Holder Vehicle Information
Was the Insured's Vehicle Damaged?	Yes No Unknown
If Yes, please provide the following:
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Tag Number
Vehicle Color
Is the Vehicle Drivable?	Yes No Unknown
Where can the Vehicle be Seen? (Location, Phone Number)
Please Give a Short Description of the Damage to the Vehicle

Accident Information
Who is Reporting this Accident to our Company?
Date of the Accident
Approximate Time of Accident (i.e. 00:00)	: AM PM
Where did the Accident Occur? (i.e. street name, intersection)
City Where the Accident Occurred
Police Contacted?	Yes No Unknown
Police Department Name
Any Witnesses Present?	Yes No Unknown
If yes, Please Provide Us with Witness' Name and Phone Number	-- Ext.
Please Give a Short Description of the Accident

Other Driver and Other Vehicle(s)/Property Information (Only Complete if Known or Applies)
Driver/Owner 1 (if known or applicable)
Name
Address
City, State, Zip Code	-
Phone Number	-- Ext.
Was anyone injured in this vehicle?	Yes No Unknown
If Yes, Please Give a Description (include name and extent of injuries)
Vehicle/Property Damage 1 (if known or applicable)
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Tag Number
Vehicle Color
Is the Vehicle Drivable?	Yes No Unknown
Please Give a Short Description of the Damage
Where can the Vehicle be Seen? (Location, Phone Number)
If damage is to Personal Property, Please describe Property

Driver/Owner 2 (if known or applicable)
Name
Address
City, State, Zip Code	-
Phone Number	-- Ext.
Was anyone injured in this vehicle?	Yes No Unknown
If Yes, Please Give a Description (include name and extent of injuries)
Vehicle 2 (if known or applicable)
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Tag Number
Vehicle Color
Is the Vehicle Drivable?	Yes No Unknown
Please Give a Short Description of the Damage
Where can the Vehicle be Seen? (Location, Phone Number)

Driver/Owner 3 (if known or applicable)
Name
Address
City, State, Zip Code	-
Phone Number	-- Ext.
Was anyone injured in this vehicle?	Yes No Unknown
If Yes, Please Give a Description (include name and extent of injuries)
Vehicle 3 (if known or applicable)
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Tag Number
Vehicle Color
Is the Vehicle Drivable?	Yes No Unknown
Please Give a Short Description of the Damage
Where can the Vehicle be Seen? (Location, Phone Number)





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