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Auto Accident Claim
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
Step 1
Verify that everyone is safe. Check for injuries, when in doubt, please dial
911
.
Step 2
Do not discuss the incident with other parties. Limit your discussion of the incident to the police and your insurance agent. Do not admit fault.
Step 3
Write down contact information for all parties involved. Include names, phone numbers, and insurance information. In addition to contact information write details about the incident.
Step 4
If your phone has a built in camera, take pictures to perserve the scene for later review.
Step 5
Use the following form to notify us of the auto accident claim.
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Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State / Province
Required
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IA
IL
IN
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NC
ND
NE
NV
NH
NJ
NM
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VI
VT
VA
WA
DC
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code
Required
Phone
Required
Alternate Phone Number
Optional
E-Mail
Required
Policy Number
Required
Incident Overview
What date did the incident take place?
Required
January
February
March
April
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December
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1901
1900
What vehicle was involved?
Required
Was another vehicle involved?
Required
Yes
No
How severe was the damage?
Required
Minor
Moderate
Severe
Unknown
None
Is the vehicle drivable?
Required
Yes
No
Where is the vehicle currently located?
Required
What is the phone number for the location?
Optional
Incident Location
Street Address
Optional
City, State. ZIP Code
Optional
Incident Description
Describe the incident.
Required
Describe the incident.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to
contact us
.
Per the terms of our
online privacy policy
we will not resell your information to any third-party.