SUBMIT A CLAIM

Auto Claim Form

All claims reported via the Internet are processed between 8 a.m. and 11 p.m. EST. For immediate service at any time please call 1.800.387.0462.

Customer Information

Policy no.:

Insured’s name:

Operator’s name:

(if different from Insured’s)

Home phone no.:

Business phone no.:

Cell phone no.:

Vehicle Information

Year:

Make:

Model:

Claim Details

Date of loss:

Damage type:

Auto Collision Comprehensive Glass Other

Vehicle damage:

(specify location of damage on vehicle)

How loss occurred:

Bodily injuries:

Yes No

Injury description:

(specify who was injured and nature of injuries)

Once submitted, your claim will be sent to a claims representative
and you will be contacted as soon as possible.

Submit