Claim Information
Available Claim Forms
To submit a claim use one of the appropriate company links below. If none are available for your particular claim, please contact us directly.
Allstate Workplace Division
Dairyland Insurance Company
Hartford Insurance Company
Insurors Indemity Companies
Auto Claim
Name: ________________________________________ Insurance Company + Policy #: ______________________________________________
Contact Number: _________________________________________ Email Address: ______________________________________________
Year, Make, and Model of your vehicle involved: ______________________________________________________ Color of vehicle: ____________________
Were there any passengers injured in your vehicle (If so, what was injured, are they on your policy and what is their name and number): ___________________________________________________________________________________________________________________________________________
Date of Accident: _____________________________________ Time of Accident: ________________________________
Where did the accident happen: ___________________________________________________________________________________________
Were the police called? YES/NO If so, what is the report number: ________________________________________________________________________________________________________________________________________
Description of what happened: _______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Is the vehicle drivable: YES/NO
Did the airbags deploy: YES/NO
Where is the location of the vehicle now:
________________________________________________________________________________________________________________________________
Do you have a body shop in mind that you want to take it to: YES/NO If so, what body shop and address?
_______________________________________________________________________________________________________________
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