Auto Claim

Auto Insurance Claim

If more than two people are involved, please call our agency directly to report the claim.

Policy Number:

Your Name:

Contact Person

Whom should the adjuster contact about repairs?

Name:

Home Phone:

Work Phone:

Email Address:

Authority Contacted

Police Department:

Report Number:

Claim Information

Date of Loss:

Location of Loss:

Cause of Loss:

If other, describe cause of Loss:

Your Damaged Car

Year/Make/Model:

Driver's Name:

Driver's Phone Number:

Describe Your Damage:

Is the car driveable? Yes No

If not, where is the car located?

Persons Injured

Name:

Phone Number:

Nature of Injuries:

Describe Other Car:

Year/Make/Model:

Owner's Name:

Owner's Policy Holder Number:

Driver's Name:

Driver's Phone Number:

Describe Damage:

Insurance Agent/Company:

Other Information

Describe What Occurred: