🧍
Step 1: Person Reporting the Claim
First Name
Last Name
Email
Home Phone
Work Phone
Mobile Phone
Street Address
Zip Code
City
State
Step 1 of 5
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Step 2: Policy Holder
Check if same as person reporting the claim
First Name
Last Name
Policy #
Home Phone
Work Phone
Cell Phone
Street Address
Zip Code
City
State
Year / Make / Model
Driver Name
Is vehicle drivable?
Yes
No
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Step 2 of 5
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Step 3: Other Vehicle Involved
Owner First Name
Owner Last Name
Address
Zip
City
State
Owner Phone
Year / Make / Model
Driver First Name
Driver Last Name
Is the vehicle drivable?
Yes
No
Repair/Tow Info
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Step 3 of 5
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📍
Step 4: Accident Details
Date / Time of Accident
Street / Intersection
City / State
Police / Authority Name
Report #
Describe What Happened
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Step 4 of 5
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🔧
Step 5: Final Questions
Did the police respond?
SELECT ITEM
YES
NO
Did an ambulance respond?
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YES
NO
Were there any injuries?
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YES
NO
Explain injuries
Were any citations issued?
SELECT ITEM
YES
NO
Explain citations
Were any vehicles towed?
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YES
NO
Explain tow
Was weather a factor?
SELECT ITEM
YES
NO
Need a Spanish-speaking rep?
SELECT ITEM
YES
NO
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Step 5 of 5
Submit Claim