Online Claim Report

  Person Reporting the Accident (You)

Name:

Mr. Mrs. Ms.

First:

Mi:

Last:

Ways you can be reached:

Phone:

--        OR

Email:

  Policyholder (Insured)
   check if same as person reporting claim

Name:

Mr. Mrs. Ms.

First:

Mi:

Last:

Insured Vehicle:

Year:

Make:

Model:

Policy Number:

Phone:

--

  Person Making Claim (Claimant)
   check if same as person reporting claim

Name:

Mr. Mrs. Ms.

First:

Mi:

Last:

Claimant Vehicle:

Year:

Make:

Model:

Phone:

--

  Accident Information

When did the accident occur?

Date:

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008

Time:

01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

Where did the accident occur?

Town:

State:

TX AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VA WA WV WI WY

Do you need a spanish speaking representative?

No Yes

Was weather a factor?

No Yes

What type?

Rain Hail Snow Ice Other

Did the police invetsigate?

No Yes

Agency?

DPS City Sheriff Other

Was the vehicle towed?

No Yes

Where?

Did an ambulance respond?

No Yes

Were any citations issued?

No Yes

How many?

(Please include a list of citations in the What Happened box)

Were there any witnesses?

No Yes

How many?

(Please include a list of names in the What Happened box)

Were you or any passengers injured?

No Yes

How many?

(Please include a list of names in the What Happened box)