Auto Claim Form We are sorry to hear about your loss. We will work promply to have your claim processed quick and fair.   Personal Information Insureds Name & Address (Street, City, St, Address)  Phone Email Insured Driver & Vehicle Information Drivers Name Date of Accident Accident Location (St., City, State) Vehicle - Make, Model & Year Describe Damage to Vehicle Is vehicle Driveable?      Yes     No      Explain circumstances of Accident Other Driver and Vehicle Information Name  Phone and Address Insurance Company and Policy # Vehicle - Make, Model & Year Describe Damage to Vehicle Injuries, Authorities & Witnesses Any Injured Drivers or Passengers?      Yes     No If yes, please explain. Authority on the Scene. Any tickets issued? (if yes please explain) Any witnesses. (if yes please list) If you would like to share any additional information or we didn't give you enough room above, please feel free to use this space.