Auto Insurance Report a Claim – Hanson Insurance Agency, Inc.

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

If more than two people are involved please call our agency directly to report the claim

Policy Number*

Your Name

First Last

Contact Person:

Whom should the adjuster contact about repairs?

Name*

First Last

Email Address*

Work Telephone Number

Home Telephone Number*

Authority Contacted:

Police Department

Report Number

Claim Information:

Date of loss

Location of claim

Cause of loss

Describe, if other cause of loss:

Your damaged car:

Vehicle Year

Please enter a number from 1894 to 3000.

Vehicle Make

Vehicle Model

Driver's Name

First Last

Driver's Address

Street Address Address Line 2 City State ZIP Code

Driver's phone number:

Is the car drivable?

Yes
No

If not, where is it located?

Persons Injured:

Injured Name

First Last

Injured Address

Street Address Address Line 2 City State ZIP Code

Injured phone number:

Nature of injuries

Describe Other Car:

Other Vehicle Year

Please enter a number from 1894 to 3000.

Other Vehicle Make

Other Vehicle Model

Owner's Name

First Last

Owner's Address

Street Address Address Line 2 City State ZIP Code

Owner's phone number:

Describe damage

Insurance agent/company

Comments

Describe What Occured:

Inquiry or Other Comments:

Captcha

PLEASE NOTE: Insurance coverage cannot be bound without a written binder from our office

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