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Car Insurance Claim Form Template

Streamline Your Claims Process with Our User-Friendly Template

Filing a car insurance claim can be overwhelming, especially when you're in distress after an accident. This template is designed to help you gather all necessary details efficiently and accurately, ensuring your claim process is smooth. You'll enjoy clear guidance for policyholders, easy organization of critical information, faster claims processing by insurers, and enhanced accuracy to minimize delays. Experience the benefits of a streamlined approach and get started with our live template today.

Use this Template (FREE) Live Preview
Your full name
Email address
Phone number
Mailing address (street, city, state, ZIP)
Are you the policyholder?
Yes
No
Policy number
Policyholder full name (if different from above)
Your relationship to the policyholder
Please Specify:
Preferred contact method for updates
Email
Phone call
Text message
Any
Date of incident
Time of incident (include AM/PM or 24-hour format)
Incident location (address or nearest intersection)
Type of incident
Please Specify:
Brief description of what happened
Was your vehicle drivable after the incident?
Yes
No
Was the vehicle towed?
Yes
No
How many vehicles were involved (including yours)?
1
2
3 or more
Unsure
Fault assessment (to the best of your knowledge)
Not at fault
Partially at fault
At fault
Unsure
Vehicle year
Vehicle make and model
License plate number
Vehicle Identification Number (VIN)
Odometer reading at time of incident (approximate)
Areas of damage on your vehicle
Please Specify:
Any pre-existing damage in the affected areas?
Yes
No
Unsure
Repair shop (if selected or preferred)
Current vehicle location
At residence
At repair facility
At storage yard or impound
At workplace
Unsure
Other
Please Specify:
Were there any injuries?
Yes
No
Unsure
Who was injured? (select all that apply)
Driver
Passenger(s)
Pedestrian
Other road user
Third-party driver
None
Prefer not to say
Did anyone receive medical attention at the scene?
Yes
No
Unsure
Was another vehicle or property involved?
Yes
No
Unsure
Third-party full name (primary contact)
Third-party phone number
Third-party insurance company
Third-party policy number
Third-party vehicle license plate
Witness names and contact information
Were there any independent witnesses?
Yes
No
Unsure
Was the incident reported to the police?
Yes
No
Unsure
Police report number (if available)
Police agency and/or officer name (if known)
Do you have photos or documents to share for this claim?
Yes
No
Not yet
Preferred method to send documents
Email
Portal upload
In person at repair shop
By mail
Not applicable
Which coverages may apply? (select all that apply)
Comprehensive
Collision
Third-party property
Third-party fire and theft
Uninsured/underinsured motorist
Personal injury protection/medical payments
Not sure
Brief details of prior claims (dates and types)
Any related auto insurance claims in the past 3 years?
Yes
No
Prefer not to say
I confirm the information provided is true and accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Signature
Date signed
I consent to be contacted and for my data to be processed for the purpose of handling this claim.
Yes
No
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Paper art illustration depicting a car insurance claim form template for FormCreatorAI article

When to use this form

Use this template right after a crash, theft, vandalism, or storm damage to your vehicle. You can capture facts while they are fresh: where it happened, who was involved, injuries, photos, and repair estimates. It suits policyholders, fleet managers, and agents who need consistent details to open a claim fast. Submit it for a parking-lot fender bender, a hit-and-run on a city street, hail dents in your driveway, or a break-in while traveling. If another driver is involved, you can add their insurer and contact info to speed coordination. For prescription reimbursements unrelated to an auto incident, route those to the Medicare prescription claim form.

Must Ask Car Insurance Claim Questions

  1. What happened, where, and when?

    Clear facts, time, and location let adjusters confirm coverage, check reports, and prioritize your case. If this is not a vehicle incident, submit the Claim form instead.

  2. Who was driving the vehicle at the time?

    Driver identity and license status determine coverage and any exclusions. It also helps match the driver to your policy and speed contact for statements.

  3. Were there injuries and was a police report filed?

    Injury details guide medical support and reserve setting; a report number helps verify facts quickly. This reduces later disputes and delays with other carriers.

  4. What vehicles or property were damaged?

    Listing all damage, including third-party property, defines liability and repair scope. It ensures we schedule the right inspections and notify other parties.

  5. Do you have photos, video, repair estimates, or witness contacts?

    Evidence shortens investigation time and supports accurate payouts. Uploading it now prevents follow-up emails and speeds settlement.

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