SWI Claims Commercial Auto Loss Notice

Policy Holder Information

Fields marked with a red star (*) are required.

Name of Insured

First Last

Policy Number*

Contact Name*

First Last

Contact Email*

Enter Email Confirm Email

Mailing Address (on policy)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Primary Phone Type*

Secondary Phone

Secondary Phone Type

Agency Name*

Agency Contact Name*

Agency Contact Number*

Loss Information

Date Loss Occurred*

Time Loss Occurred*

: HH

MM

Check If Unknown

Where Did The Loss Occur?*

Address Where Loss Occurred (If Different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Information

Description of Accident

Upload a File

Drop files here or

Upload up to 5 photos with your claim by clicking the "browse" button and locating photos on your device.

Police or Fire Department Contacted?

Police Department
Fire Department
Both
None

Report Number

Type of Loss (check all that apply)

Fire
Theft
Lightning
Hail
Flood
Wind
Other

Type (if other)

Probable Amount of Entire Loss

Please enter a dollar amount.

Tell Us Who to Contact Regarding This Claim*

When Is the Best Time to Contact This Person?*

: HH

MM

Who Is Submitting This Claim?*

Other Vehicle/Property Damaged

Vehicle #

Year

Make

Model

Body Type

V.I.N.

Carrier or Agency Name

Policy Number

Describe Property (Other Than Vehicle)

Owner's First & Last Name

First Last

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner's Phone No.

Driver's First & Last Name

First Last

Driver Address Same as Owner

(Check if same as Owner)

Driver's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe Damage

Injured Parties

Number of Injured Parties

Name of Injured Party #1

First Last

Address of Injured Party #1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No. of Injured Party #1

Type of Injured Party #1

Injured Party 2 Details

Name of Injured Party #2

First Last

Address of Injured Party #2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No. of Injured Party #2

Type of Injured Party #2

Injured Party 3 Details

Name of Injured Party #3*

First Last

Address of Injured Party #3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No. of Injured Party #3

Type of Injured Party #3

Injured Party 4 Details

Name of Injured Party #4

First Last

Address of Injured Party #4

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No. of Injured Party #4

Type of Injured Party #4

Witnesses or Passengers

Number of Witnesses or Passengers

Witness/Passenger #1 Name*

First Last

Witness/Passenger #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Witness/Passenger #1 Phone*

Witness/Passenger 2 Details

Witness/Passenger #2 Name

First Last

Witness/Passenger #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Witness/Passenger #2 Phone

Witness/Passenger 3 Details

Witness/Passenger #3 Name

First Last

Witness/Passenger #3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Witness/Passenger #3 Phone

Additional Remarks

Please Enter Any Additional remarks Here

Claim Submission

PLEASE NOTE: You must click CONTINUE below to review your information and then submit before your claim is processed.

Comments

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