FILE A CLAIM/INCIDENT

Auto Accident Claims/Incidents

We just had an accident. Now what?

DO

DON'T

Take a breath
Put the vehicle in park
Turn on hazard lights
Check for injuries
Call 911 and report the accident
Call supervisor
Take pictures
Cooperate with the police
Get information
Listen, look, and take notes

Admit fault
Apologize
Offer advice
Discuss accident
Discuss previous accidents
Tell anyone "It will be ok"
Say you are "sorry" even if you are at fault

File an Auto Accident Claim/Incident

All incidents must be reported as soon as possible, even if you think no claim will be presented.

Is this an Auto Claim?

If NOT, please File a General Claim

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Claim or Incident?

Claim

Incident

Housing Authority or Insured Entity*

Policy Number*

e.g. "00000-PLEAF", "TC-00973" or "NP-00000". Your policy number can be found in your policy packet.

Name

First Last

Your phone*

Your email*

Driver Information

Driver's name*

First Last

License plate #*

Last 4 of vehicle VIN #*

Accident Information

Date of accident*

MM slash DD slash YYYY

Time of accident

Hours

Minutes

AM/PM

Description of accident

Location of accident*

Cross streets or landmarks

Other driver / Vehicle information

The information about the other party involved in the accident or incident. Optional is no other driver/vehicle involved

Other driver's name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Primary

Phone

Alternate

Vehicle make

Vehicle model

Vehicle year

Vehicle color

License plate

Auto Insurance company

Auto Insurance phone

Auto Insurance policy number

Damage to Vehicle(s)

Insured vehicle damage*

Describe the damage to the insured entity's vehicle

Is the vehicle operable?*

Yes

Other vehicle damage

Describe the damage to the other party's vehicle, if applicable

Is their vehicle operable?

Yes

Personal injury

Was anyone injured?

Driver injury

Driver's passenger(s) injury

Other party's driver injury

Other party's passenger(s) injury

Indicate all parties who sustained an injury

Were there any witnesses?*

Yes

Witness name

First Last

Witness address

Street Address Address Line 2 City State ZIP Code

Witness phone

Primary

Witness phone

Alternate

Add another Witness?

Yes

Additional Witness name

First Last

Additional Witness address

Street Address Address Line 2 City State ZIP Code

Additional Witness phone

Primary

Additional Witness phone

Alternate

Police officer information

Name

First Last

Badge #

Enforcement agency

City Police

County Police

State Patrol

Other

Tickets or citation issued?

Yes

Report #

Is there other significant information you would like to share?

Vehicle accident report or supporting documents

If a motor vehicle accident report has been filed, please attach a copy. (Files allowed: doc, docx, pdf, png, jpg.)

Drop files here or

Accepted file types: jpg, doc, docx, pdf, png, Max. file size: 128 MB, Max. files: 5.

ELECTRONIC SIGNATURE*

I certify that the information on the application is true and accurate to the best of my knowledge. I understand that if alternate information becomes available, it may result in a change of premium or policy/coverage cancellation. By submitting I am providing my electronic signature.

CAPTCHA

File an Auto Accident Claim/Incident

All incidents must be reported as soon as possible, even if you think no claim will be presented.

Is this an Auto Claim?

If NOT, please File a General Claim

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Claim or Incident?

Claim

Incident

Housing Authority or Insured Entity*

Policy Number*

e.g. "00000-PLEAF", "TC-00973" or "NP-00000". Your policy number can be found in your policy packet.

Name

First Last

Your phone*

Your email*

Driver Information

Driver's name*

First Last

License plate #*

Last 4 of vehicle VIN #*

Accident Information

Date of accident*

MM slash DD slash YYYY

Time of accident

Hours

Minutes

AM/PM

Description of accident

Location of accident*

Cross streets or landmarks

Other driver / Vehicle information

The information about the other party involved in the accident or incident. Optional is no other driver/vehicle involved

Other driver's name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Primary

Phone

Alternate

Vehicle make

Vehicle model

Vehicle year

Vehicle color

License plate

Auto Insurance company

Auto Insurance phone

Auto Insurance policy number

Damage to Vehicle(s)

Insured vehicle damage*

Describe the damage to the insured entity's vehicle

Is the vehicle operable?*

Yes

Other vehicle damage

Describe the damage to the other party's vehicle, if applicable

Is their vehicle operable?

Yes

Personal injury

Was anyone injured?

Driver injury

Driver's passenger(s) injury

Other party's driver injury

Other party's passenger(s) injury

Indicate all parties who sustained an injury

Were there any witnesses?*

Yes

Witness name

First Last

Witness address

Street Address Address Line 2 City State ZIP Code

Witness phone

Primary

Witness phone

Alternate

Add another Witness?

Yes

Additional Witness name

First Last

Additional Witness address

Street Address Address Line 2 City State ZIP Code

Additional Witness phone

Primary

Additional Witness phone

Alternate

Police officer information

Name

First Last

Badge #

Enforcement agency

City Police

County Police

State Patrol

Other

Tickets or citation issued?

Yes

Report #

Is there other significant information you would like to share?

Vehicle accident report or supporting documents

If a motor vehicle accident report has been filed, please attach a copy. (Files allowed: doc, docx, pdf, png, jpg.)

Drop files here or

Accepted file types: jpg, doc, docx, pdf, png, Max. file size: 128 MB, Max. files: 5.

ELECTRONIC SIGNATURE*

CAPTCHA

We just had an accident. Now what?

DO

Check yourself for injuries and seek medical attention
Check on passengers and other vehicle occupants
Call the police and report the accident
Secure the accident scene
Notify your employer immediately
Exchange information with other parties
Gather license plate numbers and vehicle descriptions
Use caution when speaking about the accident
Complete all required employer reports

DON'T

Leave the scene
Make admissions of fault or discuss the accident beyond required parties
Provide statements or sign documents without authorization
Tamper with evidence or move vehicles unless necessary for safety
Delay notification to your employer
Discourage involvement of law enforcement
Offer or accept payment or settlement at the scene
Post or share information about the accident