Auto Claim Information

Our Insured

Named Insured *

Driver Involved *

Phone # *

Date of Accident *

Time of Accident *

Location of Accident *

Any Injuries? * — If none, write "None"

Vehicle Involved *

Policy # *

Brief Description of Accident *

Damage to Insured Vehicle *

Is Vehicle Drivable? *

Yes

Chosen Body Shop *

Wearing Seatbelt? *

Yes

Did Airbags Deploy? *

Yes

Child Car Seat in Vehicle? *

Yes

Any Passengers? * — If none, write "None"

Police Report Filed? * — If none, write "None"

Law Enforcement Agency

Other Vehicle Involved *

License Plate # *

Driver Involved *

Driver's License # *

Address *

Phone # *

Date of Birth *

Insurance Company *

Policy # *

Any Injuries? * — If none, write "None"

Damage to Other Vehicle *

Any Passengers in Other Vehicle? * — If none, write "None"

Did you notify the customer of the deductible, if it applies in this situation?

Collision Ded.

Comp Ded.

Did you notify the customer whether they have Rental Reimbursement coverage on their policy?

Was the claim reported to State Farm? Confirm claim number received.

Claim #

Alias