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