71 County St., Attleboro Massachusetts

 We are a Trusted Choice Agent

 

Auto Accident Report Form

***Note: This form does not replace contacting your agent. This report is simply a vehicle to inform your agent of a loss, and allow the agency to prepare accordingly. An agent will attempt to contact you immediately upon receipt of this report.

Insured Information

Insured Name
Insured Address
City State Zip
Home Phone Daytime Phone
E-Mail

Contact Information

Contact Name (if different)
Where to Contact
When to Contact
Contact Home Phone (if different) Contact Business Phone (if different)

Loss Information

Location of accident
Description of accident
Authority information(reports filed, violations cited)

Insured Vehicle Description

Vehicle #1 (Year, Make & Model)

Owner Information (if different from insured)

Owner Name
Owner address

Driver Information (if different from insured)

Driver Name
Driver Address
 

Following are the insurance companies direct claims numbers.   Please use these telephone numbers only in case of a loss. For normal service and billing issues please leave us a message on our Customer Support Form or in our general voice mailbox and we will get back to you as quickly as possible.

In the event of a loss, please take the necessary steps to secure your property from further loss.  Please save any damaged material and take photographs if possible.  Retain all receipts and invoices.

 

 


 

© Copyright, 2000 by Holman Insurance Agency, Inc. (All rights reserved).