Report any auto accident or loss as soon as possible. Complete what you know and return to info@iprotectinsurance.com or call 256-444-2041. Attach photos, the police report, and the other party's insurance card if available.
IMPORTANT - WHAT TO DO AFTER AN ACCIDENT
Make sure everyone is safe. Call 911 for injuries and call police to the scene when possible.
Do NOT admit fault or agree to pay for damages at the scene.
Photograph all vehicles, plates, damage, the scene, and the other driver's license and insurance card.
Get names and phone numbers of all drivers, passengers, and witnesses.
Forward any letter, demand, or lawsuit papers to us IMMEDIATELY.
Insured / Business Name
*
Policy Number
Insurance Company
Person Reporting
*
First Name
Last Name
Best Phone
*
Format: (000) 000-0000.
Email
example@example.com
Best Time to Contact
2 ACCIDENT / LOSS DETAILS
Date of Accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Location (street, intersection, city, state)
*
Police Dept. / Report #
Type of Loss:
*
Vehicle collision
Single vehicle
Hit & run
Hit animal
Parked car hit
Glass only
Theft
Vandalism
Hail / weather
Fire
Flood
Other
Describe what happened (direction of travel, road and weather conditions, who hit whom):
*
Was anyone injured? If yes, list names and injuries in Section 5.
*
Yes
No
Was a ticket or citation issued to any driver?
*
Yes
No
3 YOUR VEHICLE & DRIVER
Year / Make / Model
*
VIN (last 6 is fine)
*
License Plate / State
Mileage
Driver Name
*
First Name
Last Name
Driver Phone
*
Format: (000) 000-0000.
Driver's License # / State
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose of Trip (business, personal, delivery)
Did driver have owner's permission? (Y/N)
Is driver an employee? Title
Describe Damage to Your Vehicle
*
Where Can Vehicle Be Seen Now?
Drivable? (Y/N)
*
Do you need a rental vehicle or towing assistance?
*
Yes
No
Page 1
Back
Next
Other Driver Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner Name (if different)
First Name
Last Name
Insurance Company
Policy Number
Claim # (if known)
Year / Make / Model
License Plate / State
Describe Damage to Other Vehicle / Property
5 INJURED PERSONS, PASSENGERS & WITNESSES
INJURED PERSONS, PASSENGERS & WITNESSES
Rows
Name
Phone
Passenger / Witness / Other (which vehicle?)
Injury (if any) & Treatment
1
2
3
4
Accident Diagram (optional - sketch by hand or email to us)
Show streets, direction of travel (arrows), vehicles (Vehicle 1 = yours), and point of impact. N↑
Signature
Signature
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FRAUD WARNING:
*
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly presents false information, is guilty of a crime and may be subject to fines and confinement in prison. (State-specific notices may apply.)
Submit
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