Auto (1st & 3rd party)

ONLINE CLAIM SUBMISSION

To report your claim online, please complete all applicable fields.
When you have finished entering your data, please be sure to press the ‘Submit’ button to send your information.

After pressing the ‘Submit’ button, a copy of your claim will be emailed to you.

Please Note: Once your claim has been reviewed, we will contact you directly to obtain additional information.

Insured

Named Insured
Policy#
Insured’s Address 1
Address 2
City
State
Zip Code

Contact Information

Contact Person for Insured
Phone #
Cell Phone #
Email Address *
Name of Person reporting claim
Phone #
Cell Phone #
Email Address

Loss Information

Date of Loss
Time
Location of Loss Address 1
Address 2
City
State
Zip Code
How did accident occur
Year, Make and Model of Insured Vehicle
Insured Vehicle ID #
Insured Plate
Police Department Responding
Describe Damage to Insured Vehicle
Insured Driver’s Name
Year, Make, Model, Plate of Other Vehicle
Owner of Other Vehicle
Address
Address 2
City
State
Zip Code
Driver Other Vehicle
Address 1
Address 2
City
State
Zip Code
Insurance Info of Other Vehicle
Identify Injured Parties
Identify Witnesses

Remarks

Comments
Attach a copy of police report and driver’s statement if available
Reported By
Relationship of Person Reporting Claim