Auto Insurance - Report

Auto Insurance Report a Claim

If more than 2 people are involved, please call our agency directly to report the claim.

Policy Number:

Your Name:

Contact Person:
Whom should the adjuster contact about repairs?

Name:
Home phone:
Work phone:
Email address:

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:

Year/Make/Model:
Driver's name/address:
Driver's phone number:
Describe your damage:
Is the car drive able?	Yes No
If not, where is it located?


Persons Injured:

Name and address:
Phone number:
Nature of Injuries:

Describe Other Car:

Year/Make/Model:
Owner's name/address:
Owner's PH#
Driver's name/address:
Driver's phone number:
Describe damage:
Insurance agent/company:


Describe What Occurred:

Comments and/or Other Information

Please Note: Insurance coverage cannot be bound without a written binder from our office.

Robert Wehn and Associates 2859 83rd Ct,. Darien, IL
Phone: (630) 910-9600 Fax: (630) 910-9601
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