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Report A Claim

Claim Assignment

Fill out the form below and click submit. You will receive a claim acknowledgement when the claim is set up and assigned to an adjuster.

Submit a Claim for Motor Vehicle

Choose One of Four ways to submit a claim

1. Click Here to submit a claim via your own email program.

2. If you have a completed Loss Form, you can send it to our Fax Line: 713-680-2371.

3. If you have a completed Loss Form ready to submit, you may upload it here and send it without filling out the rest of the form.

Upload claim assignment or any additional attachments:

4. Or you can just fill out the form below

*Required Fields

Contact Information

*First Name:

*Last Name:

Phone Number:

Fax Number:

*Email:

Submit By Company

Customer Number:

First Name:

Last Name:

Company Name:

Address:

City:

State:

Zip Code:

Contact Phone Number:

Contact Fax Number:

Contact Email:

Policy Information

Policy Number:

Policy Effective Date:

Loss Information

Date of Loss:

Cusomter Claim #:

Location of Loss:

Description of Loss:

Were Police called:

Was a Ticket Issued:

Name of Police Dept:

Insured Information

Insured Person / Company:

Contact First Name:

Contact Last Name:

Insured Address:

City:

State:

Zip Code:

Insured Home Phone:

Insured Work Phone:

Insured Vehicle Information

Vehicle Plate / Tag Number:

Vehicle Make:

Vehicle Model:

Vehicle Vin:

Driver's First Name:

Driver's Last Name:

Driver's Home Phone:

Driver's Work Phone:

Damage Description:

Is Car Driveable:

If not, where is vehicle:

Injured Party First Name:

Injured Party Last Name:

Description of Injury:

Claimant Information

Claimant First Name:

Claimant Last Name:

Claimant Address:

City:

State:

Zip Code:

Claimant Home Phone:

Claimant Work Phone:

Claimant Vehicle Information

Vehicle Plate / Tag Number:

Vehicle Make:

Vehicle Model:

Vehicle Vin:

Driver's First Name:

Driver's Last Name:

Driver's Home Phone:

Driver's Work Phone:

Damage Description:

Is Car Driveable:

If not, where is vehicle:

Injured Party First Name:

Injured Party Last Name:

Description of Injury:

Witness Information

Claimant First Name:

Claimant Last Name:

Claimant Address:

City:

State:

Zip Code:

Claimant Home Phone:

Claimant Work Phone:

Special Instructions:

If you have any additional attachments please attach them in section two at the top of this form.

Claims Management System

CID:

User:

Pass: