Personal and Farm Claim Form
Your Name
*
Named Insured (if different from above)
Policy Number
Type of Claim
*
Auto/Boat/Motorcycle/ATV/RV
Home/Dwelling Fire
Personal Articles/Inland Marine/Scheduled Items
Farm/Farmowners
Insurance Company
*
Progressive
Safeco
Farmers Mutual
Grinnell
Travelers
Columbia
Nationwide
ECM
Other
Date of Loss/Accident
*
/
Month
/
Day
Year
Date
Time of Loss/Accident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Peril
*
Fire
Wind
Hail
Lightning
Personal Liability
Farm Liability
Other
Cause of Loss
*
Insured Accident w/ Other Vehicle
Insured Accident w/ No Other Cars
Hail
Deer
Fire
Theft
Other
Description of Loss/Accident
*
Driver Name
*
First Name
Last Name
Passenger Names
Insured's Vehicle Involved
*
Year, Make, Model
Description of Damage to Insured's Vehicle
*
Description of Damage
*
Other Drivers Name
First Name
Last Name
Other Drivers Phone Number
-
Area Code
Phone Number
Other Drivers Insurance & Policy #
Other Vehicle/Property Damage
*
Location of Loss/Accident
*
Were There Injuries
*
Yes
No
Unknown
Details of Injuries
*
Name and Description
Your Email
example@example.com
Your Primary Phone Number
*
-
Area Code
Phone Number
Your Secondary Phone Number
-
Area Code
Phone Number
Were the police or fire department contacted?
*
Police Department
Fire Department
No
Department Name
Submit
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