Accident Claim Form

If you have had an accident, please complete the information below.

Your Information

Your Name

Address

Policy #

Primary Contact #

Your Vehicle Involved

Your Vehicle – Year, Make, Model

Color of Your Car

Damaged Area of Your Car

Other Driver Information

Other Driver's Name

Other Driver's Primary Phone #

Other Vehicle – Year, Make, Model

Accident Information

Date of Accident

Time of Accident

Street Where Accident Occurred

Cross Street (if any)

City

County

State

Police or Sheriff's Department That Responded

Police Report #

Citations Issued – To Whom

What Was the Citation For

Who Was at Fault

What Happened

Injuries

Was Anyone Injured?

Yes No

Once you click Submit, this information will be sent to our claims department. Please expect a call within 24–48 hours. Should you not receive that call, please call us at 1-888-278-8121.