Auto Insurance Claim

Please complete as much information as possible. At a minimum, please provide your contact information so that we can assist you with processing your claim.

Date of Accident       Time     am pm
Policy Number     

Insured Information
Insured Name     
Address
City, State  Zip ,     
Residence Phone  
Business Phone

Loss
Location of Accident
City, State ,  
Authority Contacted
Report #
Description of
Accident

Insured Vehicle
 
Year Make     Model 
Plate Number State 
V.I.N. Number
Owner's Name
Owner's Address
City, State ,  
 
Driver's Name
Driver's Address
City, State ,  
Description of
Damage
Estimate Amount  $

Property Damage
Description of
Property
(If auto, year,
make,
model,
plate#)
Other Veh/Prop Ins Yes   No
Company/
Agency Name 
Policy #
Owner's Name
Owner's Address
City, State ,  
 
Driver's Name
Driver's Address
City, State ,  
 
Description of
Damage
Estimate Amount  $

Injured #1
Name
Address
City, State ,  
Phone
  Pedestrian    Insured Vehicle    Other Vehicle
Extent of Injury

Injured #2
Name
Address
City, State ,  
Phone
  Pedestrian    Insured Vehicle    Other Vehicle
Extent of Injury

Injured #3
Name
Address
City, State ,  
Phone
  Pedestrian    Insured Vehicle     Other Vehicle
Extent of Injury

Witnesses or Passengers
Name
Address
City, State ,  
Phone
  Pedestrian    Other Vehicle    Other
Specify Other

Submitted by
Name
Agency
Address
City, State ,  
LOC Code
Date of Claim
Phone
Fax
Email

 

Summit Insurance Agency

5170 Darrow Rd. 
Hudson, Ohio, 44236
Phone: (330) 655-0655
E-Mail: info@summitinsurance.net 

Copyright © 2006 - Summit Insurance Agency