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Auto Report Claim

Auto
General Liability
Property
Mgmt and Prof Liability
Surety

Report a Claim

By using this service, you can expedite the handling of your claim. After you complete the notice, it is sent electronically to the appropriate claims department personnel who will contact you within 24 hours. For more information visit the Claim Notification Center.

Auto

Progress

Contact Information

Required Fields

Name of Person to Contact

Email Address of Person to Contact

Phone Number of Person to Contact

- -

Person Reporting Claim

Are you the Policyholder, Broker, or Other?

Phone Number of Person Reporting Claim

- -

Email Address of Person Reporting Claim

Check here if the Reporting Person is the same as the Contact Person

Policy Profile

Policy Number

Policy Holder Name (individual or company)

Policy Holder Street Address

Policy Holder City

Policy Holder State

Policy Holder Phone

- -

Spouse's Name

Loss Location

Street Address

City

State

Zip

Loss Location Code

Description of Loss

Date of Loss

Type of Loss

Description of Loss

Has Police Report or Fire Dept. Report been filed?

If Yes, Police Department and Case Number

Injuries Sustained

Injuries

YesNo

Name of Injured

Address of Injured

Date of Birth of Injured

Phone # of Injured

- -

Insured or Claimant?

InsuredClaimant

Description

Name of Injured

Address of Injured

Date of Birth of Injured

Phone # of Injured

- -

Insured or Claimant?

InsuredClaimant

Description

Name of Injured

Address of Injured

Date of Birth of Injured

Phone # of Injured

- -

Insured or Claimant?

InsuredClaimant

Description

Policyholder Vehicle

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

YesNo

Airbags Deploy?

YesNo

Fluids Leaking from the vehicle?

YesNo

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Vehicle (2)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

YesNo

Airbags Deploy?

YesNo

Fluids Leaking from the vehicle?

YesNo

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Vehicle (3)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

YesNo

Airbags Deploy?

YesNo

Fluids Leaking from the vehicle?

YesNo

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Other Vehicle

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

YesNo

Airbags Deploy?

YesNo

Fluids Leaking from the vehicle?

YesNo

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Other Vehicle (2)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

YesNo

Airbags Deploy?

YesNo

Fluids Leaking from the vehicle?

YesNo

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Suit Information

Has Suit been filed?

YesNo

If Yes, Date Served

Venue

Submit Claim Form Here

File Attachments

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Following packages will be used to scan file(s): * MSCW 5.1.2

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