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:CollisionFireGlass BreakageTheftVandalismWind DamageOther-describe belowDescribe, 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 InformationInsurance coverage will not be canceled, bound or modified without a written confirmation from Ledbetter Insurance Agency. NameThis field is for validation purposes and should be left unchanged.