Auto Liability / Physical Damage Claim Form

The following information is required to submit an Auto Liability / Physical Damage Claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative. For more information please read our section about Vehicle Insurance for Nonprofits and for-profit Social Service Organizations.

Fields marked with a red asterisk ( *) are required.

Sender Information
Insured Vehicle Information
Body Shop Information
Upload Claim Support Material
  • Upload any claim support material you have, such as Police Reports, Hospital Reports and/or Internal Incident Reports

    Clear uploads

    Accepted file extensions: .pdf, .doc, .docx, .png, .jpg

Third Party Vehicle Information
Occurrence Information
Person(s) Injured
  • Please separate individual information by commas. For addresses and injury descriptions, leave a blank line between each entry.

    (Example: John Smith, Jane Doe, etc.)

  • Please enter the text in the image to help us verify that you are not a spammer.
    Use the blue buttons on the right of the image if you are having trouble.

  • You may also print and fax this form for processing to: (718) 389-4300