Claims Home

In Case of Accident

Report a Claim

To report a new claim on-line, please complete the form below. Note that some information is mandatory in order to complete the claim reporting process. Click on the "Submit Claim" button when complete.

Person Reporting the Claim

First Name

Last Name

Email

Home Phone Number

Work Phone Number

Cell Phone Number

Address (street, city, state, zip)

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Policy Holder

Click if same as person reporting claim

First Name

Last Name

Policy Number

Home Phone Number

Work Phone Number

Cell Phone Number

Address (street, city, state, zip)

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Other Vehicle Involved in Accident

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Accident Information

Date of Accident

Time of Accident

Street or Intersection

City and State

Describe what happened. Be sure to list the names of any witnesses or injured passengers. Also describe any injuries which may have occurred.

Additional Information

Yes No Did the police respond?
Police Agency		Police Report #
Yes No Did an ambulance respond?
Yes No Were any citations issued?
Yes No Were any vehicles towed?
Yes No Was weather a factor?
Rain Hail Snow Ice Other
Yes No Do you need a spanish speaking representative?