Auto Insurance Claim: The Great Lakes Insurance Group

Auto Insurance Claim

General
Policy Number:
Submitted By:
Date Of Loss:
Location Of Claim:
Cause Of Loss Description:
Contact Person Info
Contact Name:
Contact Home Phone:
Contact Work Phone:
Contact Email:
Authorities Contacted
Police Dept:
Police Report Number:
Your Vehicle Information
Year/Make/Model:
Drivers Name And Address:
Driver Phone:
Describe Damage:
Where Is Your Car Now:
Other Vehicle and Driver
Other Car Year/Make/Model:
Other Owner Name:
Other Owner Phone:
Other Driver Name:
Other Driver Address:
Other Drivers Phone:
Other Car Damage:
Other Driver Insurance:
Person(s) Injured
Persons Injured:
Injured Person Phone:
Injury Description:
Describe What Occurred Other Comments:
I understand that submitting a claim at this web site does not confirm coverage or authorize payment. A claims representative will verify coverage and contact me to complete the claims process. If you have not received a response from us within one business day, please contact us again. Thank you.