Auto Accident Claim Form

Policyholder Information
Policy Number
		Check this box if Policyholder Name/Telephone Number matches "Contact Information".
If you checked the box above, please skip to "Accident Information", otherwise complete the questions in this shaded area.
Policyholder Name
Daytime Phone
Policyholder - Address
Address (line 2)
Policyholder - City
Policyholder - State	Zip

Damage Information
Was Policyholder Vehicle Damaged? Yes No
If Policyholder Vehicle WAS Damaged, complete the questions in this shaded area.
Vehicle Year
Vehicle Make
Vehicle Model	(e.g., Civic, Taurus, Sentra ...)
Describe the Damage to the Vehicle


Where can the vehicle be seen? (give address or phone # if known)


Describe Damage to Other Vehicles

Describe Damage to Other Property (if applicable)


Other Involved Parties
Provide Contact and Vehicle information for ALL parties involved in the accident.
Fraud Warning Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil penalties and criminal prosecution for insurance fraud.

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Accident Information
Date of Accident	/ / mm / dd / yyyy
Time of Accident	hh:mm AM PM
		Check this box if Accident Location matches Policyholder Address.
If you checked the box above, please skip to "Brief Description of Accident", otherwise complete the questions in this shaded area.
Accident Location - Address
Accident Location - City
Accident Location - State	Zip
Brief Description of Accident

Police/Fire Contacted?	Yes No
Police/Fire Report Number
Police/Fire Department Name
Any Witnesses Present?	Yes No
Did Injuries Result From Accident?	Yes No
If there WERE injuries, please provide Name, Address, Phone Number and Extent of the Injuries in the box below.