Auto Claims Form

Step 1 of 7

Policy Number
Date of Loss
MM slash DD slash YYYY
Time

:

AM/PM
Owner/Insured Information
Name
First Last
Company Name*
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Cell
Policy Number

Driver's Information
Check if same as owner
- Yes
- No
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell
Related to Insured
Date of Birth
MM slash DD slash YYYY
Driver's License #
License State
Purpose of use
Used with permission?
- Yes
- No

Insured's Vehicle
Year
Make
Model
VIN #
Plate #
State
Vehicle #

Loss Information
Address*
Street Address Address Line 2 City State ZIP Code
Description of Accident*
Authority Contacted
Report Number
Describe Damage
Where can vehicle be seen?

Property Damaged
Property Damaged
Vehicle
- Yes
- No
Make
Model
Year
Plate #
State
Company/Agent Name
Policy Number
Owner's Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell
Describe Damage
Driver's Name
First Last
Same as owner?
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell

Injured
Injured
- First Choice
- Second Choice
- Third Choice
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell
Date of Birth
MM slash DD slash YYYY
Extent of Injury

Witnesses or Passangers
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell
Vehicle
- Insured's
- Other
Independent Witness
- Yes
- No
Remarks
Reported By
First Last
Reported To
First Last
Date Reported
MM slash DD slash YYYY
Please attach photos regarding this claim
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