File A Business Auto Insurance Claim

CONTACT INFORMATION
Primary Contact
First Last
Mobile Phone
Email
Mailing Address
Street Address City State ZIP Code
Best Time To Contact

: HH

MM
INSURED INFORMATION
Is The Insured A Person Or Business?
- Person
- Business
Is The Primary Contact The Named Insured?
- Yes
- No
Name Of Insured
First Last
Name Of Business
Insured's Phone
Insured's Email
Insured's Mailing Address
Street Address City State ZIP Code
Date Of Birth
Date Format: MM slash DD slash YYYY
Marital Status
- Married | Civil Union
- Single | Divorced | Widowed
Spouse's Name
First Last
Spouse's Date Of Birth
Date Format: MM slash DD slash YYYY
Spouse's Phone
Spouse's Email
Federal ID Number (If Known)
INSURANCE POLICY INFORMATION
Carrier Information
- Erie Insurance
- Nationwide Insurance
- Travelers Insurance
- State Auto
- National General Insurance
- Progressive Insurance
- UPC Insurance
- Universal Property & Casualty
Policy Number
LOSS INFORMATION
Date Of Loss
Date Format: MM slash DD slash YYYY
Approximate Time Of Loss

: HH

MM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
What Kind Of Loss Is This?
- My Vehicle Was In An Accident
- An Animal Damaged My Vehicle
- Windshield | Window Damage
- Weather Damaged My Vehicle
- I Was Injured (No Damage To My Vehicle)
- My Vehicle, Or Its Content, Was Stolen Or Vandalized
- Towing Reimbursement
- Something Else Happened To My Vehicle
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
INSURED VEHICLE
Year
Make
Model
Vehicle Identification Number
Body Type
- Private Passenger
- Truck
- Trailer
- Camper
Plate Number
Registration State
State
Vehicle Owner - Same As Named Insured?
- Yes
- No
Owner's Name & Address & Contact Info (Phone | Email)
Driver Is Same As First Named Insured From Above?
- Yes
- No
Driver's Name
First Last
Driver's Phone
Driver's Address
Street Address City State ZIP Code
Relation To Insured
- Family Member
- Employee
Driver's Date Of Birth
Date Format: MM slash DD slash YYYY
Driver's License Number
State Of License
State
Purpose Of The Vehicle's Use
- Normal Daily Use
- Pleasure
- Business Use
Did The Driver Have Permission To Use The Vehicle?
- Yes
- No
Describe The Damage To The Insured Vehicle
Was A Standard Child Passenger Restraint System (Child Seat) Installed In The Vehicle At The Time Of The Accident?
- Yes
- No
Was The Standard Child Passenger Restraint System (Child Seat) In Use By A Child During The Time Of The Accident?
- Yes
- No
Did The Child Passenger Restraint System (Child Seat) Sustain A Loss At The Time Of The Accident?
- First Choice
- Second Choice
- Third Choice
Estimated Amount Of Damage To Insured Vehicle?
Where (Location) & When Can The Insured Vehicle Be Seen?
OTHER VEHICLE | PROPERTY DAMAGED INFORMATION
Was Another Vehicle(s) | Property | Person Damaged/Injured In The Accident (Check All That Apply)
- Vehicle(s)
- Property
- Person(s)
- No Other Vehicles | Property | Persons Damaged/Injured
Other Vehicle(s) Information
Please Give Year | Make | Model of all other vehicles involved in the accident
Damaged Property Information
Describe Property That Was Damaged
Other Vehicle | Property Insured?
- Yes
- No
- I Don't Know
Insurance Carrier
Policy Number
Property | Vehicle Owner's Information
Include Name | Address | Phone
Vehicle Driver's Information (If Different Than Owner)
Include Name | Address | Phone
Describe Damage | Injuries
Estimated Amount of Vehicle | Property Damage
Where Can The Damage Be Seen?
INJURED PARTY INFORMATION
Were Any Injuries Sustained?
- Yes
- No
How Many People Were Injured?
- 1
- 2
- 3
- 4+
Name Of 1st Injured Party
First Last
Address Of 1st Injured Party
Street Address City State ZIP Code
Phone Of 1st Injured Party
Where Was The 1st Injured Party
- Pedestrian
- Insured's Vehicle
- Other Vehicle
Age Of 1st Injured Party
Description of 1st Injured Party's Injuries
Name Of 2nd Injured Party
First Last
Address Of 2nd Injured Party
Street Address City State ZIP Code
Phone Of 2nd Injured Party
Where Was The 2nd Injured Party
- Pedestrian
- Insured's Vehicle
- Other Vehicle
Age Of 2nd Injured Party
Description of 2nd Injured Party's Injuries
Name Of 3rd Injured Party
First Last
Address Of 3rd Injured Party
Street Address City State ZIP Code
Phone Of 3rd Injured Party
Where Was The 3rd Injured Party
- Pedestrian
- Insured's Vehicle
- Other Vehicle
Age Of 3rd Injured Party
Description of 3rd Injured Party's Injuries
Name Of 4th Injured Party
First Last
Address Of 4th Injured Party
Street Address City State ZIP Code
Phone Of 4th Injured Party
Where Was The 4th Injured Party
- Pedestrian
- Insured's Vehicle
- Other Vehicle
Age Of 4th Injured Party
Description of 4th Injured Party's Injuries
WITNESSES OR PASSENGERS
Were The Any Passengers Or Witnesses?
- Yes
- No
How Many Witnesses Or Passengers?
- 1
- 2
- 3
Name Of 1st Witness/Passenger
First Last
Address of 1st Witness/Passenger
Street Address City State ZIP Code
Phone Of 1st Witness/Passenger
Location of 1st Witness/Passenger
- Insured Vehicle
- Other Vehicle
- Other (Explain)
Explain Other Location Of 1st Witness/Passenger
Name Of 2nd Witness/Passenger
First Last
Address of 2nd Witness/Passenger
Street Address City State ZIP Code
Phone Of 2nd Witness/Passenger
Location of 2nd Witness/Passenger
- Insured Vehicle
- Other Vehicle
- Other (Explain)
Explain Other Location Of 2nd Witness/Passenger
Name Of 3rd Witness/Passenger
First Last
Address of 3rd Witness/Passenger
Street Address City State ZIP Code
Phone Of 3rd Witness/Passenger
Location of 3rd Witness/Passenger
- Insured Vehicle
- Other Vehicle
- Other (Explain)
Explain Other Location Of 3rd Witness/Passenger
Upload Any Files
Drop files here or

CONTACT INFORMATION

INSURED INFORMATION

INSURANCE POLICY INFORMATION

LOSS INFORMATION

INSURED VEHICLE

OTHER VEHICLE | PROPERTY DAMAGED INFORMATION

INJURED PARTY INFORMATION

WITNESSES OR PASSENGERS

Share