Auto Accident Claim Form
Insured Name *
Policy Number *
Address *
City *
State *
Zip Code *
Country *
Contact Phone Number *
Contact Email *
Liability Claim Information
Person to Contact for Claim: *
Date of accident: *
MM
/
DD
/
YYYY
Location *
Authority Contacted: *
Please give a detailed description of the accident: *
Please describe any property damage (Type, Model, etc.): *
Insured vehicle:
Year *
Make *
Model *
License Plate Number *
Name of Driver? *
Estimated amount of loss: *
Where can insured vehicle be seen? *
Other vehicle:
Year *
Make *
Model *
License Plate Number *
Other Vehicle Owner's Name *
Address *
City *
State *
Zip Code *
Phone *
The original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.
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