File an Auto Claim Submit an insurance claim on a church-insured vehicle Auto Claim Contact information Your name * Your email address Your phone number Alternate contact checkbox Someone else will be the contact person regarding this claim. Alternate contact section (conditional logic) Contact person's name * Contact person's email address * Contact person's phone number * Basic claim information Name of church/school that sponsored event * Date of accident * Time of accident (if known) 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Location of accident * Location of accident Address or nearest intersection Address or nearest intersection Additional location information (optional) Additional location information (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Description of accident * Was the accident reported to police? * Yes No Police report section (conditional logic) Date reported * Report number * Name of investigating organization * Were any citations issued? * Yes No Church-insured vehicle information Year * Make * Model * VIN number * Name of registered owner * Name of driver * Driver's date of birth * Driver's email address * Driver's phone number * Driver's mailing address * Driver's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Reason for vehicle use at time of accident * Pathfinder outing, youth group, etc. Was the vehicle used with permission? * Yes No Was the driver injured? * Yes No Describe damage to vehicle * Address where vehicle may be seen for an estimate * Address where vehicle may be seen for an estimate Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Were there any passengers in the church-insured vehicle? Yes No Passengers of church-insured vehicle (conditional logic) Name of passenger * Passenger's email address * Passenger's phone number * Passenger's mailing address * Passenger's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Was the passenger injured? * Yes No plus1 Add another passenger minus1 Remove this passenger Damaged property and other vehicle information Type of damage PropertyVehicleBothNo other property or vehicles were damaged Describe damaged property * Other vehicle information (conditional logic) Describe damage to vehicle * Year * Make * Model * Licence plate number * Insurance company * Policy number * Name of registered owner * Name of driver * Driver's email address * Driver's phone number * Driver's mailing address * Driver's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Was the driver injured? * Yes No Were there any passengers? * Yes No Witnesses Were there any witnesses? * Yes No Witness information (conditional logic) Name of witness * Witness's email address * Witness's phone number * Witness's mailing address * Witness's mailing address Address line 1 Address line 1 Address line 2 (optional) Address line 2 (optional) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip plus1 Add another witness minus1 Remove this witness If you are human, leave this field blank. 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