File A Car Insurance Claim Insured Name* First Last Mobile Phone*Is It Ok For The Carrier To Text Regarding Your Claim?YesNoEmail Insurance CarrierErie InsuranceNationwide InsuranceState AutoNational General InsuranceProgressiveOtherPolicy Number (If Known) What Best Describes The Cause Of The Incident* 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 What Caused The Damage To Your Vehicle? Another Moving Car | Motorcycle | Train | Bus A Parked Car Of Fixed Object An Animal A Pedestrian A Bike How Were You Injured? While Entering Or Exiting Vehicle While A Passenger In Someone Else's Vehicle As A Pedestrian While Working On Vehicle How Was Your Vehicle Damaged? Something Was Stolen From My Vehicle My Vehicle Was Stolen My Vehicle Was Vandalized My Vehicle Was Set On Fire Approximate Date Of Loss MM slash DD slash YYYY Approximate Time Of Loss : Hours Minutes AM PM AM/PM Where Did The Incident Occur? Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are You Still At The Scene? Yes No Was Anyone Injured? Yes No I'm Not Sure Who Was Injured? (Include Names, Injuries, Contact Info, etc)What Type Of Accident Was it I was rear-ended I rear-ended someone I was in an accident with other moving cars What Type Of Accident Was it I was rear-ended I rear-ended someone I was in an accident with other moving cars What Vehicle(s) Were Involved In The Incident (Your Vehicle(s))Supply The Following Information: YEAR MAKE MODEL VIN (Vehicle Identification Number)Brief Summary Of IncidentPlease supply us with some details about the incidentPolice Information (Optional)Police Department | Official's Name | Report NumberUpload Any Files Drop files here or Select files Max. file size: 50 MB. Δ
