Claims Form

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In the event of a claim, use this form to initiate the process.

This form has 6 parts:
          1. Owner / Insured Information
          2. Vehicle Information
          3. Driver Information
          4. Accident Information
          5. Loss Information
          6. Police Information

* fields are required. Any other information that you don't know or don't have readily available can be left blank.

Owner / Insured Information (Part 1 of 6)

Policy Number:    
Name: *  
Address: *  
City, State: *  
Zip: *  
Home Phone: *  
Work Phone:    
Cell Phone:    
Best Time To Call:     Morn'g    Afternoon     Even'g

Vehicle Information (Part 2 of 6)

Year (4 digits - ex: 1960): *  
Model: *  
Vehicle Identification Number (VIN): *  
Where is the vehicle now?    
Was it towed?     Yes    No
If yes, who towed it? (Company, Address, Phone)    
Amount of tow fee:    
Describe damage to vehicle: *  

Driver Information (Part 3 of 6)

Driver Name and Address:
(Check here if same
as owner)
Driver Phone Numbers:
(Check here if same
as owner)
Marital Status:    
Date of Birth
Relationship to  
Owner / Insured:
Driver's License Number:    
State of Issue:    
Expiration Date
Restrictions on License:    
What citations, if any, 
were issued to the driver?
Vehicle used with  
owner's permission?
    Yes    No

Accident Information (Part 4 of 6)

Date of Accident
Time of Accident:    
Location of Accident:
(Street Names, City, State)
Purpose of Trip:
Describe Accident: *  

Loss Information (Part 5 of 6)

How many other vehicles and/or properties were damaged? (Do not include your vehicle.)
Please enter a number from 0 to 10
How many injuries were there? (Your vehicle and others involved)
Please enter a number from 0 to 10
How many witnesses or passengers were involved? (Your vehicle and others involved)
Please enter a number from 0 to 10

Police Information (Part 6 of 6)

Police contacted:     Yes    No
Police Report filed:     Yes    No
If yes, Police Report number:    
Officer's name and/or badge number:    
What police or fire department responded?    
Police Department Phone Number: