Auto:Report a Claim

If more than 2 people are involved, please call our agency directly to report the claim.
* Required Fields
Policy Number
Your Name

Contact Person

Whom should the adjuster contact about repairs?
Name
Home Phone
Work Phone
Email *

Authority Contacted
Police department
Report number

Claim Information
Date of loss
Location of claim
Cause of loss
Describe, if other cause of loss

Your Damaged Car
Year/Make/Model
Driver's name/address
Driver's phone number
Describe your damage
Is the car driveable?
If not, where is it located?

Persons Injured
Name and Address
Phone
Nature of Injuries

Describe Other Car
Year/Make/Model
Owner's name/address
Owner's PH#
Driver's name/address
Driver's phone number
Describe damage
Insurance agent/company
Describe what occured.

Comments and/or Other Information

Please Note: Insurance coverage cannot be bound without a written binder from our office.