Insurance Forms: Auto Insurance Claim Form

Please provide the following information so that we may process your claim:

Driver Information

Are the driver and the owner/insured the same person?
	Yes No

Please complete this section if you answered no.
Driver Name:
Address:
City:
State:
Zip:

Where to contact?
When to contact?	(day/time)

Residence Phone:	(incl. area code)
Business Phone:	(incl. area code)

Accident Information

Accident Location: (incl. city & state)
Authority Contacted:
Report Number:
Violations/Citations:
Accident Description:

Vehicle Information

Year:
Make:
Model:
Plate Number:

Describe Damage:
Estimate Amount:

Where and when can the vehicle be seen:
Where:
When:	(day/time)

Witness/Passenger Information

Witness/Passenger #1
Name:
Address:
City:
State:
Zip:
Phone:	(incl. area code)
Location:
Other Info:

Witness/Passenger #2
Name:
Address:
City:
State:
Zip:
Phone:	(incl. area code)
Location:
Other Info:

Operator's Report

Have you completed a Commonwealth of Massachusetts Operator's Report of Motor Vehicle Accident?
	Yes
	No, please send me one.

Make sure you mail it to: Downey Insurance Local or state police present at the accident Registrar of Motor Vehicles 1135 Tremont Street Boston, MA 02120-2103