Auto Accident
Claim Form
 

Personal Info
Last Name:
First Name:
City:
State:
Zip Code:
Daytime Phone:
Current Email Address:

Policy Holder Info
Policy Number:
Check this box if Policy Holder Name/Telephone Number matches Contact Person information.
Policy Holder Name:
Daytime Phone:

Policy Holder-Address:

Policy Holder- City:
Policy Holder-State:
Policy Holder-Zip:


Accident Information
Date of the Loss:
Time of the Accident:
AM PM
Check this box if Accident Location matches Policy Holder Address.
The Accident Location - Address:
The Accident Location - City:
The Accident Location - State:
The Accident Location - Zip:
Please Give a Brief Description of Accident:
Was The Police / Fire Department Contacted?
Yes No
Police / Fire Department Report Number (if applicable):
Police / Fire Department Name (if applicable):
Were There Any Witnesses Present?
Yes No
Did Any Injuries Result From The Accident?
Yes No
If "Yes" to above, please provide: Name, Address, Phone # and Extent of Injuries of Those Injured:

Damage Info
Was The Policy Holder's Vehicle Damaged?
Yes No
If "Yes" to the above question please provide the following:
Policy Holder's Vehicle Year:
Policy Holder's Vehicle Make:
Policy Holder's Vehicle Model:
Please Give a Brief Description of Damage:
Where Can We Go to View the Vehicle:
Please Describe Damage to Other Vehicle ( if applicable ):
Please Describe Any Additional Property Damage ( if applicable):

Fraud Warning
Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil penalties and criminal prosecution for insurance fraud.