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Submit a Claim
Vehicle Incident Report
Step
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– General Information
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General Information
If you are involved in an accident, please contact your local law enforcement authority as soon as it is safe to do so. If possible, take pictures of the vehicle(s) involved and gather contact information from witnesses.
My Name
*
First
Last
Phone
*
Email
*
Disclaimer
Any person who knowlingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I agree
Date and Location
Date of the Accident (Date of Loss)
*
MM slash DD slash YYYY
Approximate Time
*
:
Hours
Minutes
AM
PM
AM/PM
In what city did the incident occur?
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Street Address/Intersection
Your Vehicle Information
Vehicle Year
*
Vehicle Make (Example Nissan)
*
Vehicle Model (Example Altima)
*
VIN#
*
The VIN number is located on the lower left side of the windshield or on the inside of the driver’s door jam.
Towing Information
Were you able to drive the vehicle from the scene?
*
Yes
No
Was the vehicle towed from the scene?
Yes
No
Current Vehicle Location
Contact Number
Passengers
Were any passengers in the vehicle at the time of the accident?
*
Yes
No
If yes, how many?
*
Injuries
If you feel you are seriously injured, please seek medical attention before continuing this form.
Was anyone injured in the accident?
*
Injuries in my vehicle
Injuries in other vehicle(s)
No injuries
Other
Was anyone transported from the scene via ambulance?
Yes
No
Not Sure
Name of the medical care facility?
Accident Description
Tell us what happened in your accident
*
Was a citation/ticket issued at the scene?
*
Yes
No
Citation Number
Was a police report filed?
Yes
No
Police Agency?
Police report number?
Witnesses
Was there an independent witness? (not involved in the accident)
*
Yes
No
Contact information
Other Involved Party
Was there another party involved?
Yes
No
How Many Vehicles Were Involved?
Other Driver's Name
Other Driver's Insurance Card
Other Driver's Plate Number
Other Driver's VIN Number
Other Driver's Vehicle Make & Model
Photos
Photos of Vehicle Damage/Impact Area
Drop files here or
Select files
Max. file size: 256 MB, Max. files: 10.
Please provide at least 3 photo of your vehicle damage, any other vehicle’s damage, and photo of the accident area with a landmark or street sign.
Police Documents, Driver's License, Registration, Insurance Cards, Exchange of Information Report, etc.
Drop files here or
Select files
Max. file size: 256 MB.
Text additional photos to 240-428-6084
