Automobile Loss Claim Form

Please fill out the following form and click the submit button. An agent will contact you within 24 hours.

Date of Loss
Time

Personal Information First Name Last Name Street City Postal Code Telephone - day Telephone - evening Email
Preferred day

Loss Information Location of loss
Authority contacted
Report #
Violations/Citations
Description of Accident

Your Vehicle

# of vehicles Year Make Model Year

Owner's Info

First Name Last Name Phone - evening Phone - daytime Address

Driver's Info

PROPERTY DAMAGE

First Name
Last Name
Telephone - daytime Telephone - evening Relation to Insured Date of Birth Driver License # State

Used with Permission? Yes No

Purpose of Use
Describe Damage
Estimate Amount Where can vehicle be seen? When? Other Insurance on vehicle

Describe property
(if auto, please provide year, make, model and plate #)
Describe damage
Where can damage be seen? Property Owner - First Name Property Owner - Last Name Telephone - daytime Telephone - evening Estimate amount

Is there other vehicle/property insurance? Yes No

Company or agency name Policy # Other driver? (check if same as owner) First name Last name Address

WHO IS INJURED?

Were you (the insured) the injured? Yes No

Describe your injuries

Others injured?
Name and Address	Phone (area + num)	Pedestrian	Other driver?	Extent of injury




Witnesses or Passengers
Name & Address	Phone (area + num)	Your vehicle?	Other vehicle?	Other (specify)

By submitting this form I agree that all of the included information is truthful to the best of my knowledge and I understand that fraudelent claims are illegal and may be prosecuted. Ellis Insurance's acceptance of this form does not constitute confirmation of coverage.