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  • Create a Claim Report - Automobile

Create a Claim Report - Automobile

Your Wawanesa Insurance policy number is required to complete this claim form. This can be found on your:

  • Policy Declarations page (upper right corner)
  • Policy Billing Stub (upper right corner)
  • Proof of Insurance or "pink card" (lower left corner)

If this is a claim emergency, please call 1-844-WAWANESA (929-2637). We're available 24/7.

* indicates a required field


    Your Information

    First Name*
    Last Name*
    Please type at least one phone number below *
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Email Address
    Insurance Company Name
    Insurance Company Policy #

    Loss Information

    Our Policy Number* ANC
    Date of Loss*
    (mm/dd/yyyy)
    Time of Loss* :
    Street/Freeway Location*
    City*
    Country
    State*
    Province*

    Describe the Accident or Incident*


    Other Party Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages

    Our Insured Information

    Same as Your Information
    First Name*
    Last Name*
    Address
    City
    Country
    Province
    Postal Code
    State
    Zip Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Is The Driver Of The Insured Vehicle Same As Above?

    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Driver Of The Insured Vehicle

    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Our Insured Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages

    Police Report

    Was a police report or joint report obtained?


    Other Parties

    Are there additional Other Parties not reported above?*


    How Many?

    Solo Vehicle Loss - No Other Party Involved


    Other Party 1 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 1 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 2 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 2 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 3 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 3 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 4 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 4 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 5 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 5 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages

    Passengers / Witnesses

    Were there any passengers in any of the involved vehicles?*


    How Many?  
    No passengers in any involved vehicles


    Passenger 1 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Numberr
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 2 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Numberr
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 3 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Numberr
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 4 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Numberr
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 5 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Numberr
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Were there any witnesses?*


    How Many?  
    No Witness


    Witness 1 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 2 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 3 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 4 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 5 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries




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