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Claims Team
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Search for:
auto accident claim
Auto Accident Claim
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Name
First
Last
Name of the Insured (Personal Name, Company Name, etc.)
Phone
Email
Date of Accident
Date Format: MM slash DD slash YYYY
Time of Accident
:
HH
MM
AM
PM
Weather Conditions
Description of Accident
Location of Accident
Street Address
Address Line 2
City
State
ZIP / Postal Code
Were authorities contacted (i.e., police department, fire department, etc.)
Yes
No
Report Number
Which agency handled this matter (i.e. Lafayette Fire Department, Texas Highway Patrol, etc.)?
Was medical response required?
Yes
No
Insured Driver Information
Name of Driver
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Insurance Company & Policy Number
Drivers License # and State
Auto Year / Make / Model
VIN Number
Were there any passengers in the vehicle?
Yes
No
Name (Passenger 1)
First
Last
Phone (Passenger 1)
Was there a second passenger in the vehicle?
Yes
No
Name (Passenger 2)
First
Last
Phone (Passenger 2)
Were there any witnesses?
Yes
No
Name (Witness 1)
First
Last
Phone (Witness 1)
Was there a second witness?
Yes
No
Name (Witness 2)
First
Last
Phone (Witness 2)
Were there any injuries?
Yes
No
Describe injuries:
Was there a second vehicle involved in the accident?
Yes
No
Insured Driver 2 Information
Name of Driver 2
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Insurance Company & Policy Number
Drivers License # and State
Auto Year / Make / Model
VIN Number
Were there any passengers in vehicle 2?
Yes
No
Name (Passenger 1)
First
Last
Phone (Passenger 1)
Was there a second passenger in vehicle 2?
Yes
No
Name (Passenger 2)
First
Last
Phone (Passenger 2)
Were there any witnesses for vehicle 2?
Yes
No
Name (Witness 1)
First
Last
Phone (Witness 1)
Was there a second witnesses for vehicle 2?
Yes
No
Name (Witness 2)
First
Last
Phone (Witness 2)
Were there any injuries in vehicle 2?
Yes
No
Describe injuries:
Was there a third vehicle involved in the accident?
Yes
No
Insured Driver 3 Information
Name of Driver
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Insurance Company & Policy Number
Drivers License # and State
Auto Year / Make / Model
VIN Number
Were there any passengers in vehicle 3?
Yes
No
Name (Passenger 1)
First
Last
Phone (Passenger 1)
Was there another passenger in vehicle 3?
Yes
No
Name (Passenger 2)
First
Last
Phone (Passenger 2)
Were there any witnesses for vehicle 3?
Yes
No
Name (Witness 1)
First
Last
Phone (Witness 1)
Was there a second witness for vehicle 3?
Yes
No
Name (Witness 2)
First
Last
Phone (Witness 2)
Were there any injuries in vehicle 3?
Yes
No
Describe injuries:
Was there a fourth vehicle involved in the accident?
Yes
No
Insured Driver 4 Information
Name of Driver
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Insurance Company & Policy Number
Drivers License # and State
Auto Year / Make / Model
VIN Number
Were there any passengers in vehicle 4?
Yes
No
Name (Passenger 1)
First
Last
Phone (Passenger 1)
Was there a second passenger in vehicle 4?
Yes
No
Name (Passenger 2)
First
Last
Phone (Passenger 2)
Were there any witnesses for vehicle 4?
Yes
No
Name (Witness 1)
First
Last
Phone (Witness 1)
Was there a second witness for vehicle 4?
Yes
No
Name (Witness 2)
First
Last
Phone (Witness 2)
Were there any injuries in vehicle 4?
Yes
No
Describe injuries:
Additional comments:
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