Submit a Claim

Tell us what happened and we will take it from there. Complete the form to the best of your ability. If anything is urgent, call us at (626) 332-2258.

Go to: Auto accident | Any other incident (injury, property damage, anything else)

Auto Accident

For an accident involving a vehicle your organization owns. You can attach photos of the damage and the scene.

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This field is for validation purposes and should be left unchanged.

Vehicle Owner

The business or organization that owns the vehicle.

Name of business or organization that owns the vehicle(Required)

Address

Street Address Address Line 2 City State ZIP Code

Phone number(Required)

Driver and Vehicle

Name of driver(Required)

First Last

Driver's age

Please enter a number from 14 to 110.

Driver's license number

License state

Driver's address

Street Address Address Line 2 City State ZIP Code

Driver's phone

Vehicle year, make and model(Required)

VIN #

Damage to vehicle

Did you take any photos?

Yes

Attach photos or documents

Photos of the damage or the scene, a police report, or any other documents. Up to 10 files, 20 MB each.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, heic, heif, webp, pdf, doc, docx, Max. file size: 20 MB, Max. files: 10.

Purpose of trip

Collision

Date of collision(Required)

Time of collision

Location (street and city)(Required)

Was a police report made?

Yes

Name of reporting officer

Citation or report #

Agency

Witness name

Witness phone number

Briefly describe what happened

Your Details

The person completing this form.

Your name(Required)

First Last

Your email address(Required)

Submit a Claim

Auto Accident

Vehicle Owner

Driver and Vehicle

Collision

Your Details

Any Other Incident

Your Organization

The Incident

Witness

Injured Party

Your Details

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