Automobile REPORT A PERSONAL AUTOMOBILE CLAIM If this is an automobile glass only claim, please click here.For all other carriers, please complete the form below: Please enter the insured’s personal information so we can look up your policy and contact you regarding your claim. Name of Insured:(required) Mailing Address Line #1:(required) Mailing Address Line #2 City:(required) State:(required) Zip Code:(required) Policy Number: Who should we contact regarding this claim? Contact Name:(required) Contact Phone:(required) Contact Email:(required) How should we contact you? Email Phone Please provide us with some information about the vehicle involved in the accident: Vehicle Year (i.e. 1999):(required) Vehicle Make (i.e. Ford):(required) Vehicle Model (i.e. Mustang):(required) Owner of Vehicle:(required) Driver of Vehicle:(required) Location of Vehicle:(required) Describe the Vehicle Damage:(required) Is the vehicle driveable?(required) Yes No Please provide us with some information about the accident: Accident Location:(required) Authority Contacted: Case Number: Describe the Accident:(required) Was the accident your fault? Yes No Any information on other party: Were there any injuries? Yes No If Yes, please describe the injuries: Terms: This claim cannot be considered filed under the notification guidelines of your policy unless you receive a reply from our firm. If you haven’t received a reply within 48 hours, please contact us via phone. If you have any additional paperwork, please fax to Robin Roberts 706-883-8915 after submitting this form.