National General RV Insurance Claim (Agent)

Step 1 of 5: Policyholder Contact 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 RV Insurance Claim (Agent)

Step 2 of 5: Other Party Contact Information

Do you have the other party's information? *
Yes No

Other Party Information

First Name

Last Name

Address

City

State

ZIP Code

Email Address

What is the other party's primary phone number?

Ext.

Name of Other Party's 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 RV Insurance Claim (Agent)

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 RV Insurance Claim (Agent)

Step 5 of 5: Review and Submit

Policyholder's Information Edit

Policy Number:

First Name:

Last Name:

Address:

City/State/Zip:

Email Address:

Primary Phone/Ext:

Secondary Phone/Ext:

Other Party Information Edit

Role:

First Name:

Last Name:

Address:

City/State/Zip:

Email Address:

Primary Phone/Ext:

Other Party Ins Co:

Policy Number:

Claim Number:

Injuries Edit

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:

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:

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

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:

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:

National General RV Insurance Claim (Agent)

Step 1 of 5: Policyholder Contact Information

National General RV Insurance Claim (Agent)

Step 2 of 5: Other Party Contact Information

National General RV Insurance Claim (Agent)

Step 3 of 5: Loss Information

National General RV Insurance Claim (Agent)

Step 4 of 5: Property Damage Information

National General RV Insurance Claim (Agent)

Step 5 of 5: Review and Submit