File Auto Claim

CONTACT INFORMATION

Fields marked (*) are mandatory

FIRST NAME

LAST NAME

CONTACT PHONE

E-MAIL

POLICY NUMBER

NAME OF INSURANCE COMPANY ON POLICY

ONLY POLICY CHANGE REQUEST DISCLAIMER

I understand that NO changes to my policy or coverage are binding by submitting this Online Policy Change Request. This change request will only be considered bound upon confirmation from my Broker/Agent.

REQUESTED EFFECTIVE DATE OF CHANGE

I have read and agree with the above
(Box must be checked before request can be sent)*

VEHICLE INVOLVED

Fields marked (*) are mandatory

MAKE

YEAR

MODEL

LOSS GENERAL

DATE OF LOSS

CAUSE OF DAMAGE

ESTIMATED DAMAGE

The following section is applicable to Accident only

DRIVER FIRST NAME

DRIVER LAST NAME

RELATIONSHIP TO APPLICANT

TIME OF THE ACCIDENT

NUMBER OF CARS INVOLVED

POLICE NOTIFIED

Yes No

EST. PERCENTAGE AT FAULT

LOCATION OF THE ACCIDENT

STREET/HIGHWAY

CITY/TOWN

STATE

SHORT DESCRIPTION

OTHER PARTY INFORMATION (IF AVAILABLE)

OTHER DRIVER NAME

ADDRESS

HOME PHONE

WORK PHONE

DRIVER'S LICENSE

LICENSE PLATE

LICENSE STATE

INSURANCE COMPANY

POLICY NUMBER

VEHICLE YEAR/MAKE/MODEL

DAMAGE DESCRIPTION

The following section is applicable to Theft only

TIME LOSS DISCOVERED

DATE POLICE NOTIFIED

VEHICLE RECOVERED

Yes No

DATE VEHICLE RECOVERED

SHORT DESCRIPTION

Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction

File Auto Claim

Our process is transparent

Products

Services

Locations

Products

Services

Locations

Great Northern Insurance © All Rights Reserved.

Great Northern Insurance Agency Our Dedication Ensures Your Satisfaction

Our process is transparent

Products

Services

Locations

Products

Services

Locations

Great Northern Insurance © All Rights Reserved.

Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction