automobile/vehicle claim report

emergency claim situations

If a claim emergency requires immediate assistance after business hours, please call our 24-hours Emergency Claims Hotline. Simply call 800-222-8711 and follow the prompts.

non-emergency claim situations

Submitting a report online is a convenient way to provide us with the information necessary to begin to process your claim in a non-emergency. A customer support associate will contact you for any additional information.

When another vehicle is involved, a state accident report from the state in which the accident occurred is often required.Use these links if you need a Massachusetts, New Hampshire, Rhode Island, and Vermont frorm or contact us for other states. Please provide us with a copy of the completed form by fax at 978-562-4122 or dropping it off at any office. If you prefer to email us a scan of the document, we recommend using our Secure Email tool, which protects your private information with encryption.

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vehicle claim report
Please be sure to click on "Submit" at the end when complete. A "Thank You" will display as confirmation of your submission.
contact information
vehicle owner's name

address

street address
Street Address 2
city	state
zip code	Country

email
daytime phone
home phone

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vehicle claim report
accident information
date
month - day - year
accident location
street address
accident locaiton city
city
description

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vehicle claim report
insured vehicle
vehicle information
year - make - model
registration number
plate/registration number
registration state
registration state
where can vehicle be seen
where can vehicle be seen?
describe damage
driver information
name
driver's license number
driver's license number
driver's license state
license state
date of birth
date of birth
driver's phone
daytime phone

driver address (if different from owner)

street address
Street Address 2
city	state
zip code	Country

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vehicle claim report
other vehicle or property damage
was another vehicle involved or other property damaged in the accident?
yesno
vehicle information
year - make - model
other vehicle registration
plate/registration number
registration state
registration state
insurance company name
city
describe damage to other vehicle or other property
other driver information
name

address

street address
Street Address 2
city	state
zip code	Country

other driver phone
phone
other vehicle owner information
name

Address

street address
Street Address 2
city	state
zip code	Country

other vehicle owner phone
phone

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vehicle claim report
injured persons
was anyone injured?
yesno
injured person 1
name
injured person 1 - phone
phone

injured person 1 - address

street address
Street Address 2
city	state
zip code	Country

injured person 2
name
injured person 2 - phone
phone

injured person 2 - address

street address
Street Address 2
city	state
zip code	Country

injured person 3
name
injured person 3 - phone
phone

injured person 3 - address

street address
Street Address 2
city	state
zip code	Country

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vehicle claim report
witnesses or passengers
were there any passengers in your vehicle or other witnesses?
yesno
witness/passenger 1
name
witness passenger 1 - phone
phone

witness/passenger 1 - address

street address
Street Address 2
city	state
zip code	Country

witness/passenger 2
name
witness/passenger 2 - phone
phone

witness/passenger 2 - address

street address
Street Address 2
city	state
zip code	Country

witness/passenger 3
name
witness/passenger 3 - phone
phone

witness/passenger 3 - address

street address
Street Address 2
city	state
zip code	Country

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vehicle claim report
Thank you for taking the time to complete this claim report. Please click the "submit" button to send your information to us.

NOTE: Submitting this online claim report helps to expedite processing of your claim. Please note that insurance companies often require separate claims forms to also be completed and submitted along with your signature.
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automobile/vehicle claim report

emergency claim situations

non-emergency claim situations

vehicle claim report

contact information

vehicle claim report

accident information

vehicle claim report

insured vehicle

vehicle claim report

other vehicle or property damage

vehicle claim report

injured persons

vehicle claim report

witnesses or passengers

vehicle claim report

Thank you for taking the time to complete this claim report. Please click the "submit" button to send your information to us.