Claim and Report Forms

Affidavit of facts for accidents without a police report

All questions must be answered.

Insured/policy holder information
Last name: First name: Middle initial:
Phone:
Home Address:

City: State: ZIP:

Business Name:
Business Address:

City: State: ZIP:
Business Phone:
Vehicle information
Year / Make / Model: VIN# Color:
License plate #: State: Plate year:

Has Vehicle been damaged in the past 3 years? 
Describe damages:
Was Vehicle repaired?  

Lienholder:
Prior insurance company
Name:
Address:

City: State: ZIP:

Agent’s name:
Phone number:
Policy #: Cancellation date:
Other Driver
Last name: First name: Middle initial:
Address:

City: State: ZIP:

Driver's license #: State: Work phone#:
Insurance company: Policy #:

Vehicle Year / Make / Model: Color:
License plate #: State: Plate year:
Loss report
In your own words, briefy give the facts and describe your movements and location of your vehicle prior to and at the time of the accident:

Date of accident: Time:
Place: Were the police called to the scene?

Location of Vehicle, if hit and run:
Reason Vehicle was at this location:
Your e-mail address:
BY SUBMITTING THIS FORM, I ASSERT THAT I HAVE ANSWERED THE ABOVE QUESTIONS AND THEY ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
  

Please notify the Insurance Systems claims department to report this claim.
Claims department phone number 1-800-749-5440

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