Personal Auto Claims

Policy Information

Insured Name:
Insured Phone:

Name of Person Reporting Claim:
Name of Person Reporting Phone:

Insurance Company:
Policy Number:

Best Time to Call:

Claim Information

Date of Loss:
Amount of Claim:
Describe What Happened:
Insured Vehicle:
Driver of Vehicle:

---

Is The Vehicle Drivable?

Where is Vehicle Located:
Describe The Damage:

---

Was There Damange to Someone Else's Vehicle or Property?

Person/Property Owner's Name:
Person/Property Owner's Phone:
Describe The Damage:

---

Was Anyone Injured?

Name of Injured:
Type of Injury:
Did They Seek Medical Treatment?:    Yes    No

Name of Injured:
Type of Injury:
Did They Seek Medical Treatment?:    Yes    No

---

Any Questions or Comments:

  

• Obtain names and addresses of drivers and occupants of other vehicle(s).
• Obtain license numbers of vehicles involved.
• Obtain names and addresses of witnesses.
• Obtain name of other person's insurance company.
• Report the accident to the police department of other designated authority.
• Report the accident to us.