Automobile Claim Report

View Form Instructions

Date of Loss(Required)

Date Reported(Required)

Insured Name(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location of Loss

Description of Accident

Insured Vehicle

Year(Required)

Make(Required)

Model(Required)

V.I.N.(Required)

Plate(Required)

Extent of Damages(Required)

Present Location(Required)

Driver Information

Driver Name(Required)

First Last

Date of Birth(Required)

License No(Required)

State(Required)

Other Vehicle

Year (Other Vehicle)

Make (Other Vehicle)

Model (Other Vehicle)

Extent of Damages (Other Vehicle)

Address (Other Vehicle)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver Information (Other Vehicle)

Insurance

Company Name(Required)

Policy No.(Required)

Agent Name

Phone

Injured?

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Extent of Injury

Witnesses

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Impact

Is damaged auto essential to business?(Required)

Yes

How?

Reported By(Required)

CAPTCHA

Instructions

If still on the scene:

Contact police
Obtain information about other people involved in the accident or anyone who may have witnessed the accident.
- Name
- Address
- Phone number
- Insurance Carrier
- Policy Number
- Etc.
Take photos of the accident, if camera available.
Have vehicle towed if unable to drive.

If not on the scene:

The insurance company will contact you within 48 hours
Obtain two estimates for repair if vehicle can be driven.
The claim adjuster will either ok one of these two estimates or send an appraiser to see the vehicle.
The claim adjuster will deal directly with the other people involved in the accident; you should not deal with them yourself.

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