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Auto Report Claim

Claims

Auto Report Claim

Auto
General Liability
Property
Mgmt and Prof Liability
Surety

Report a Claim

New Jersey Bulletin 20-19_PIP Carriers

By using this service, you can expedite the handling of your claim. After you complete the notice, it is sent electronically to the appropriate claims department personnel who will contact you within 24 hours. For more information visit the Claim Notification Center.

Auto

Progress

Contact Information

Required Fields

Required Fields

Name of Person to Contact

* Name of Person to Contact Required

Email Address of Person to Contact

* email Required Email address not formatted correctly

Phone Number of Person to Contact

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Person Reporting Claim

* Person Reporting Claim Required

Are you the Policyholder, Broker, or Other?

* Broker, or Other Required

Phone Number of Person Reporting Claim

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Email Address of Person Reporting Claim

* email Required Email address not formatted correctly

Check here if the Reporting Person is the same as the Contact Person

Policy Profile

Policy Number

Policy Holder Name (individual or company)

*Policy Holder Name Required

Policy Holder Street Address

Policy Holder City

Policy Holder State

* state Required

Policy Holder Phone

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Spouse's Name

Loss Location

Street Address

* Street Address Required

City

* City Required

State

* state Required

Zip

Loss Location Code

Description of Loss

Date of Loss

* date Required Must be a valid date: MM/DD/YYYY Future dates not allowed

Type of Loss

* Type of Loss Required

Description of Loss

* Description of Loss Required

Has Police Report or Fire Dept. Report been filed?

* Police Report Required

If Yes, Police Department and Case Number

* Police Department Required

Injuries Sustained

Injuries

Yes

No

Name of Injured

* Name of Injured Required

Address of Injured

Date of Birth of Injured

* date Required Must be a valid date: MM/DD/YYYY Future dates not allowed

Phone # of Injured

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Insured or Claimant?

Insured

Claimant

*Insured or Claimant? Required

Description

Name of Injured

* Name of Injured Required

Address of Injured

Date of Birth of Injured

* date Required Must be a valid date: MM/DD/YYYY Future dates not allowed

Phone # of Injured

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Insured or Claimant?

Insured

Claimant

*Insured or Claimant? Required

Description

Name of Injured

* Name of Injured Required

Address of Injured

Date of Birth of Injured

* date Required Must be a valid date: MM/DD/YYYY Future dates not allowed

Phone # of Injured

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Insured or Claimant?

Insured

Claimant

*Insured or Claimant? Required

Description

Policyholder Vehicle

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

E-Mail address not formatted correctly

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

Yes

No

Airbags Deploy?

Yes

No

Fluids Leaking from the vehicle?

Yes

No

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Vehicle (2)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

E-Mail address not formatted correctly

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

Yes

No

Airbags Deploy?

Yes

No

Fluids Leaking from the vehicle?

Yes

No

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Vehicle (3)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

E-Mail address not formatted correctly

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

Yes

No

Airbags Deploy?

Yes

No

Fluids Leaking from the vehicle?

Yes

No

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Other Vehicle

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

E-Mail address not formatted correctly

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

Yes

No

Airbags Deploy?

Yes

No

Fluids Leaking from the vehicle?

Yes

No

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Other Vehicle (2)

Year, Make, Model

VIN #

License Plate#

Driver Name

Contact # for Driver

Contact Email for Driver

E-Mail address not formatted correctly

Address for Driver

Primary Point of Impact or Damage Area

Estimate of Loss?

Drivable?

Yes

No

Airbags Deploy?

Yes

No

Fluids Leaking from the vehicle?

Yes

No

Contact Name

Address of Vehicle Location

Phone Number of Vehicle Location

- -

Area code required Invalid Area Code Telephone exchange required Invalid exchange Invalid Number

Suit Information

Has Suit been filed?

Yes

No

If Yes, Date Served

* date Required Must be a valid date: MM/DD/YYYY Future dates not allowed

Venue

Submit Claim Form Here

File Attachments

File size is limited to 3 (MB) per file. Maximum Files: 5

Following packages will be used to scan file(s): * MSCW 5.1.2

Allowed file types: .doc .docx .pdf .jpg .jpeg .gif .bmp .png .tif .rar .zip .xls .xlsx

Please verify that you are not a robot.

By checking this box, I confirm that I’ve read and understand the fraud language pertaining to the submission of this claim. * Required

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Supplier Diversity

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