Auto Loss Claim Form

Section 1
Personal Information
*Indicates required field.

*First Name:
*Last Name:
Phone:
 
Street Address:
City:
State:
Zip:
*Email Address:
 
Person to Contact:
Contact Number:
*Security question: What is three plus two?

Date and Time of Loss

Date of loss (MM/DD/YYYY): / /
Time of Loss:
Location of Accident: Address: City: State:
Description of Accident:

Insured Vehicle

Year, Make and Model:
Driver's Name and Address:
(check if same as owner)
Same as owner
Insurance Company and Expiration Date
Describe Damage:
Where can vehicle be seen:

Property Damaged

Describe Property
(If auto, year, make, model, plate number)
Company or Agency Name & Policy Number
Owner's Name & Address
Home Phone:
Business Phone:
Describe Damage:

Injured

Name & Address
Phone (area code & number)
Extent of Injury

Witnesses or Passengers

Name & Address
Phone (area code & number)
Remarks