File an Auto Claim Submit an insurance claim on a church-insured vehicle Auto Claim Contact information Your name * Your email address Your phone number Alternate contact checkbox Someone else will be the contact person regarding this claim. Alternate contact section (conditional logic) Contact person's name * Contact person's email address * Contact person's phone number * Basic claim information Name of church/school that sponsored event * Date of accident * Time of accident (if known) 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Location of accident * Location of accident Address or nearest intersection Address or nearest intersection Additional location information (optional) Additional location information (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Description of accident * Was the accident reported to police? * Yes No Police report section (conditional logic) Date reported * Report number * Name of investigating organization * Were any citations issued? * Yes No Church-insured vehicle information Year * Make * Model * VIN number * Name of registered owner * Name of driver * Driver's date of birth * Driver's email address * Driver's phone number * Driver's mailing address * Driver's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Reason for vehicle use at time of accident * Pathfinder outing, youth group, etc. Was the vehicle used with permission? * Yes No Was the driver injured? * Yes No Describe damage to vehicle * Address where vehicle may be seen for an estimate * Address where vehicle may be seen for an estimate Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Were there any passengers in the church-insured vehicle? Yes No Passengers of church-insured vehicle (conditional logic) Name of passenger * Passenger's email address * Passenger's phone number * Passenger's mailing address * Passenger's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Was the passenger injured? * Yes No Add another passenger Remove this passenger Damaged property and other vehicle information Type of damage Property Vehicle Both No other property or vehicles were damaged Describe damaged property * Other vehicle information (conditional logic) Describe damage to vehicle * Year * Make * Model * Licence plate number * Insurance company * Policy number * Name of registered owner * Name of driver * Driver's email address * Driver's phone number * Driver's mailing address * Driver's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Was the driver injured? * Yes No Were there any passengers? * Yes No Witnesses Were there any witnesses? * Yes No Witness information (conditional logic) Name of witness * Witness's email address * Witness's phone number * Witness's mailing address * Witness's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Add another witness Remove this witness Submit
