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Assign an Auto Claim

Online Submission Form

Auto Assignment Form

Fill out the form below to assign an auto claim. One of our claims representatives will be in touch with you in 24 hours.

    (Fields marked with * are required)

    Customer Information

    First Name*

    Last Name*

    Title

    Company*

    Address*

    City*

    State*

    Zip*

    Phone*

    Fax

    Email Address*

    Your Claim #*

    Date of Accident/Loss*

    Vehicle Information

    Vehicle Year*

    Vehicle Make*

    Vehicle Model*

    Vehicle Location*

    Vehicle Color*

    Vehicle VIN*

    License Plate*

    Injury / Damage / Coverage

    Injury / Damage

    Coverage Information

    Attachments

    Individual file size may not exceed 6MB