Auto Accident Claim Form


What to do in the event of an Auto Accident

Safety: 

  •  Make certain you and your passengers are safe – move your vehicle off the road and turn on your hazard lights.

  •  Call 911 if there are injuries or the accident is significant

  •  If you are witnessing road rage from the other party, keep your distance from them and  call 911.

 Obtain:

  • Information on the Other driver’s Insurance Card, including
  • Name
  • Address
  • Phone number
  • Insurance Company details, including (name, policy number and Ph. Number).  
  • If the other driver can not furnish the information, call 911 and obtain their License Plate Number and any information you can on the vehicle.

 Reporting:

  • Call our Agency, your Insurance Company or complete the form below – if you call the Insurance Company, please let us know when you have a moment so we can monitor the claim. 


Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Policy Number
Required
Incident Overview
What date did the incident take place?
Required
/ /
What vehicle was involved?
Required
Was another vehicle involved?
Required
How severe was the damage?
Required
Is the vehicle drivable?
Required
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
Other Drivers Informaton (e.g. Name, Phone #: etc.)
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
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.