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Create a Claim Report - Automobile

Our insured's policy number is required to report a claim online. If you do not have our insured's policy number available to you, please call us at: (800) 427-9669 or (800) 57-CLAIM to report this loss.
(This website based reporting site is monitored during normal business hours).

*indicates a required field



    Your Information

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

    Loss Information

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

    Describe the Accident or Incident*

    (Limited to 25 lines)


    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
    State
    Zip Code
    Province
    Postal 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

    Did a law enforcement agency come to this accident or incident?


    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?*


    No passengers in any involved vehicles

     

    Passenger 1 Information

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

    Injuries


    Were there any witnesses?*

    How Many?

    No Witnesses

     

    Witness 1 Information

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

    Injuries


    Verification Code