National General Auto Insurance Claim

Step 1 of 5: Other Party Information

Other Party Information

If this claim is for a single vehicle, continue to Step 2

First Name *

Last Name *

Address

City

State

ZIP Code

Email Address

What is your phone number?

Extension

Name of your insurance company?

Policy Number

Claim Number

* Required field.

Data is not yet being submitted. You will have a chance to review your information before submitting.

National General Auto Insurance Claim

Step 2 of 5: Policyholder Contact Information

Reporting Person Information

Reporter Name *

Reporter Email *

Reporter Phone *

Policyholder Information

Policy Number *

First Name *

Last Name *

Address

City

State

ZIP Code

Email Address

What is the policyholder's primary phone number?

Extension

Does the policyholder have an alternate phone number?

Yes No

Secondary Phone Ext.

* Required field.

Data is not yet being submitted. You will have a chance to review your information before submitting.

National General Auto Insurance Claim

Step 3 of 5: Loss Information

What was the date and time of the loss?
Date*

Time*

What was the location of the incident?

Street Address*

City*

State *

ZIP Code

Please describe how the incident happened and any damages sustained. *

Did the police or fire department respond? *
Yes No

Police/Fire Department Name

Police/Fire Department Report Number

* Required field.

Data is not yet being submitted. You will have a chance to review your information before submitting.

National General Auto Insurance Claim

Step 5 of 5: Review and Submit

Reporter Information Edit

Reporter Name:

Reporter Email:

Reporter Phone:

Other Party Information Edit

First Name:

Last Name:

Address:

City/State/Zip:

Email Address:

Primary Phone/Ext:

Secondary Phone/Ext:

Other Party Ins Co:

Policy Number:

Claim Number:

Policyholder's Information Edit

First Name:

Last Name:

Address:

City/State/Zip:

Email Address:

Primary Phone/Ext:

Secondary Phone/Ext:

Injuries Edit

More than two injuries in Other Party Vehicle?:

Injured Person #1 - Other Party Vehicle

Role:

First Name:

Last Name:

Address:

City/State/Zip:

Email:

Phone Number:

Type of Injury:

Injured Person #2 - Other Party Vehicle

Role:

First Name:

Last Name:

Address:

City/State/Zip:

Email:

Phone Number:

Type of Injury:

More than two injuries in Policyholder's Vehicle?:

Injured Person #1 - Policyholder Vehicle

Role:

First Name:

Last Name:

Address:

City/State/Zip:

Email:

Phone Number:

Type of Injury:

Injured Person #2 - Policyholder Vehicle

Role:

First Name:

Last Name:

Address:

City/State/Zip:

Email:

Phone Number:

Type of Injury:

Loss Information Edit

Loss Date:

Loss Time:

Incident Location:

City/State/Zip:

Police/Fire Response:

Police/Fire Department:

Police/Fire Report/Case Number:

Incident Description:

Property Damage Information Edit

Other Party Vehicle

Year:

Make:

Model:

License Plate:

License Plate State:

Drivable:

Current Vehicle Location:

Incident Location:

Driver Name:

Driver Phone Number:

Driver Address:

Driver City/State/Zip:

Driver Email:

Policyholder Vehicle

Year:

Make:

Model:

License Plate:

License Plate State:

Drivable:

Current Vehicle Location:

Incident Location:

Driver Name:

Driver Phone Number:

Driver Address:

Driver City/State/Zip:

Driver Email:

National General Auto Insurance Claim

Step 1 of 5: Other Party Information

National General Auto Insurance Claim

Step 2 of 5: Policyholder Contact Information

National General Auto Insurance Claim

Step 3 of 5: Loss Information

National General Auto Insurance Claim

Step 4 of 5: Property Damage Information

National General Auto Insurance Claim

Step 5 of 5: Review and Submit