Automobile Claim Form

Cause of the Loss:

---select an option---CollisionFireGlass BreakageTheftVandalismWindPrecipitation Falling ObjectsDeer StruckFlood

Is Vehicle Drivable?:

---select an option---YesNo Location Below

Do you require a rental vehicle?:

---select an option---YesNo

Address of undrivable vehicle:

Additional Comments:

Describe the Incident:

Your Driver Address: (include City ,State, Zip):

Describe your vehicle damages:

Describe Your Injuries:

Other Driver Address: (include City ,State, Zip):

Describe other vehicle damages:

Other Insurance Information(Agent, Company):

Describe Other Injuries:

Address of the Incident:(city,state, zip)

Any special equipment needed on the rental vehicle(both side view mirrors, Towing Hitch, Truck etc):

** Policy Number:

** Name:

** Contact Name:

** Email Address:

** Contact Phone:

Contact Fax:

Police Department:

Police Report Number:

Name of your Injured person:

Phone of your Injured person:

Date of Incident:

Your Vehicle (Make,Model,Year):

Your Driver Name:

Your Driver Phone:

Other Vehicle (Make,Model,Year):

Other Driver Name:

Other Driver Phone:

Name of other Injured person:

Phone of other Injured person:

Tme of Incident:

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Policy Information

Contact Person Whom should the adjuster contact to discuss your claim?

Authorities

Claim Information

Your Vehicle Damages This section allows you to identify the driver and damages to your covered vehicle.

Your Injuries This section allows you to identify injuries to a person in your covered vehicle.

Other Vehicle Damages This section allows you to identify the other vehicle involved in an accident.

Other Party Injuries This section allows you to identify a person incurring injuries in the other parties vehicle resulting from the accident.

Required Fields **

Please Note: You Will be contacted by a company adjuster within 24 hours.

If more than 2 vehicles are involved, or if there are any injuries in any vehicle or pedestrians, please call our agency immediately to report the claim

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