New Claim Form
I am:
A client of Price Insurance Agency
A friend or family member of a Price Insurance Client
A 3rd party involved in a claim or accident who is seeking compensation
An insurance agent or adjuster
Name of Price Insurance Policyholder
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Person completing this Form
You will receive a copy
Name of Person submitting this form
First Name
Last Name
Phone Number of Person submitting this form
Please enter a valid phone number.
Format: (000) 000-0000.
Email address of person filling out this form
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Claim
Auto
Property
Other (Work Comp, Liability, etc.)
What kind of claim are you filing?
Date of Claim
Please use best guess if not sure
Description of Incident
Please describe what happened
Incident Location
Where did it happen?
Description of property damage
Pls list vehicle & owner
Is your vehicle drivable?
Yes
No. Unable to drive safely or a headlight is broken.
I am not sure
As a result of the incident, is it safe to live in your home?
Yes
No
I am not sure
Was anyone injured?
No
Yes
I don't know
Who was injured? Please describe injuries
Were police, ambulance, or fire dept contacted?
Name the police dept that reported, if any.
Were there any witnesses
If so, need names and contact info
Do you have someone will be making repairs?
Please type name of garage or contractor
Was there another party involved in the incident?
No
Yes
Yes, but I don't have any information.
Name of other person involved
First Name
Last Name
Phone Number of other person involved
Please enter a valid phone number.
Format: (000) 000-0000.
Address of other person involved
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance company name and policy number for other party
This is very important!
Mobile phone number of person filling out this form
Please enter a valid phone number.
Format: (000) 000-0000.
Comments/Additional Information
Please tell us anything else about the claim
Upload any relevant claim files here
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