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Personal Automobile Insurance Claim Report Form
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What is your first name? *
*
What is your first name? *
What is your last name? *
*
What is your last name? *
What is your email address? *
*
What is your email address? *
Are you the contact person for this claim? *
*
Are you the contact person for this claim? *
Yes
No
What is best phone number to contact you on? *
*
What is best phone number to contact you on? *
Insured 1 - time frame for contact
Please let us know if there is a convenient time frame to reach you by phone.
Claim contact - First name
What is the claim contact's first name?
Claim contact - Last Name
What is the claim contact's last name?
Claim Contact - Email
What is the claim contact's email?
Claim Contact - Phone
What is the claim contact's phone number?
Claim contact - time frame for contact
Please let us know if there is a convenient time to reach out.
Insured Type - Person or Business
Is the insured a person or business?
Person
Business
Business Name
What is the name of the insured business?
Loss Information
What is the date of loss for this claim? *
*
What is the date of loss for this claim? *
MM slash DD slash YYYY
Time of Loss
What is the approximate time this loss occurred?
Hours
:
Minutes
AM
PM
AM/PM
Please choose the appropriate category for this claim. *
*
Please choose the appropriate category for this claim. *
Windshield or auto glass damage
Towing from disablement
All Other Auto Damages
Please provide a brief description of the location where the loss occurred, including address, if known. *
*
Please provide a brief description of the location where the loss occurred, including address, if known. *
Check the box of each aspect of this claim that applies. (Check all that apply) *
*
Check the box of each aspect of this claim that applies. (Check all that apply) *
Damage to insured vehicle
Damage to another vehicle
Damage to Property (Not a vehicle)
Injury within insured's vehicle
Injury to others
Insured vehicle stolen
Property stolen from insured vehicle
Damage to Insured Vehicle
What is the year, make and model of the insured vehicle that was damaged? *
*
What is the year, make and model of the insured vehicle that was damaged? *
Year
Make
Model
Insured Vehicle - Vin verification
Please enter the last four digits of the vehicle identification number for verification purposes.
Please provide a brief description of the insured vehicle's damage. *
*
Please provide a brief description of the insured vehicle's damage. *
Insured Vehicle Picture of Damage
Feel free to upload a picture(s) of the insured vehicle's damage?
Drop files here or
Select files
Max. file size: 128 MB.
Damage to Another Vehicle
Other Vehicle Driver Name
What is the name of the other vehicle's driver?
Other Vehicle - Year, make, model
What is the year, make and model of the other vehicle that was damaged?
Other Vehicle Address
Please enter an address for the other vehicle, if known.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Other Vehicle - Insurance Company
What is the name of the insurance company for the other vehicle?
Other Vehicle - Policy Number
What is the policy number for the other vehicle?
Other Vehicle - Description of Damage
Please enter a brief description of the damage to the other vehicle.
Other Vehicle Picture of Damage
Feel free to upload a picture(s) of the other vehicle's damage?
Drop files here or
Select files
Max. file size: 128 MB.
Damage to Property (Not a Vehicle)
Description of Property Damage
Please provide a brief description of the accident and damaged property.
Property Damage File Upload
Feel free to upload a picture of the property damage.
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 5.
Injury Within Insured's Vehicle
Insured Vehicle Injuries
Please provide the names of the injured parties along with a brief description of their injuries.
First and Last Name
Description of Injury
Injury to others
Other Vehicle Injuries
Please provide the names of the injured parties along with a brief description of their injuries.
First and Last Name
Description of Injury
Insured vehicle stolen
What is the year, make and model of the insured vehicle that was stolen? *
*
What is the year, make and model of the insured vehicle that was stolen? *
Year
Make
Model
Stolen Vehicle - Vin verification
Please enter the last four digits of the vehicle identification number for verification purposes.
Stolen Vehicle Description
Please provide any details you have about the stolen vehicle.
Property stolen from insured vehicle
Please provide a description of the property that was stolen from the insured vehicle. *
*
Please provide a description of the property that was stolen from the insured vehicle. *
Stolen Property Estimate
Please enter the approximate value of the stolen property.
Insured Vehicle Driver Information
What is the name of the driver of the insured vehicle?
What is the name of the driver of the insured vehicle?
First
Last
Driver Relationship to Insured
What is the relationship of the driver to the owner of the insured vehicle.
Driver is the vehicle owner
Family member of the vehicle owner
Employee of the vehicle owner
Authorities Involvement
Police Department Contacted?
Was the police department contacted?
Yes
No
Police Department Name
What is the name of the police department that responded?
Police Officer Name
Please enter the police officer's name.
First
Last
Police Officer Badge Number
Please enter the police officer's badge number, if available.
Police Report Number
Please enter the police report number, if available.
Police Report
Please upload a copy of the police report, if available.
Max. file size: 128 MB.
Fire Department Contacted?
Was the fire department contacted?
Yes
No
Fire Department Name
What is the name of the fire department that responded?
Documents and Comments
Relevant Workers Comp Documents
Please use this field to upload any relevant documents. (ie. Pictures, etc...)
Drop files here or
Select files
Max. file size: 128 MB.
Additional Remarks
Please enter any additional remarks or details in the space below.
Disclaimer: This online questionnaire is a tool used to gather information. A claim will NOT be submitted directly to an insurance company by submitting this form.
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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