Report a Claim

To report a claim, call 1-866-503-2778. Please complete the form below for the necessary information regarding your claim.

To download this form in .pdf format, please click here

Name of Policyholder:
Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Best place to reach you:
Type of Claim:
Description of the insured unit: Year:
Description of the insured unit: Make:
Serial # (last 6 digits only):
Trucking Company:
Please describe the damage to your vehicle - Body only, Body plus engine damage, etc.:
Is the vehicle drivable? Yes or No:
Did the engine lose water? Yes or No:
Who was operating the vehicle:
Time of the Loss:
Date of the Loss:
Street where loss occured:
City:
State:
Where you ticketed? Yes or No:
Please describe how the accident happened:
License plate of the vehicle:
State:
Model of other vehicle:
Year of other vehicle:
Make of other vehicle:
Name of other driver:
Address:
City:
State:
Zip Code:
Was this driver ticketed? Yes or No:
Does other driver carry liability insurance? Yes or No:
Insurance Company:
Policy Number:
Was the loss reported to the Police department? Yes or No:
If yes, what station # (s) Police:
Telephone #:
Officer Name:
Badge #:
Pressing Submit serves as an electronic signature on this report. Please review for accuracy.
Date of this report:
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