Auto Reporting Form

Date of Accident:

Address of Accident :

Staff Name Reporting Accident:

Contact Phone Number:

Description of Accident:

INSURED VEHICLE

YEAR-MAKE-MODEL-LAST 5 OF VIN:

Location of Insured Vehicle:

Insured Driver (Name, Address, Phone):

Passengers (Name, Address, Phone):

Was Anyone Injured:YesNo

IV Drivable: YesNo

PROPERTY DAMAGE

YEAR-MAKE-MODEL-LAST 5 OF VIN:

Location of Insured Vehicle:

Claimant Driver (Name, Address, Phone):

Passengers (Name, Address, Phone):

Was Anyone Injured: YesNo

IV Drivable: YesNo

Police Called (Department, Case Number):

Photos Obtained?

Additional Information:


Privacy Policy Confirmation

 I agree to be contacted by Alera Group in accordance to their Privacy Policy as described below.

By submitting this form, I agree I want to receive additional information from Alera Group, including by email, phone, and mail to the contact information I am submitting. I consent to Alera Group, its subsidiaries, and its service providers, processing my personal information for these purposes and as described in the Privacy Notice. I understand that I can withdraw my consent at any time.
 

Include a copy of driver exchange form
Report within 24 hours