Auto Insurance – Report a Claim

If more than 2 people are involved, please call our agency directly to report the claim.

Policy Number:
Your Name:
First Last
Contact Person:
Whom should the adjuster contact about repairs?
Name:
Home phone:
Work phone:
Email:*
Authority Contacted:
Police department:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of Loss:
Describe, if other cause of loss:
Your Damaged Car:
Year/Make/Model:
Driver's name/address:
Driver's phone number:
Describe your damage:
Is the car driveable?
- Yes
- No
If not, where is it located?
Persons Injured:
Name and address:
Phone number:
Nature of Injuries:
Describe Other Car:
Year/Make/Model:
Owner's name / address:
Owner's Phone Number:
Driver's name/address:
Driver's Phone Number:
Describe damage:
Insurance agent/company:
Describe What Occurred:
Comments and/or Other Information
Insurance coverage will not be canceled, bound or modified without a written confirmation from Ledbetter Insurance Agency.
Comments
This field is for validation purposes and should be left unchanged.

Contact Person: