If this was not vehicle damage proceed to the next step
Damaged Vehicle
Year
License Plate#
Make
Mileage
Model
Was the Vehicle Towed?
How many days will you require a rental?
Are you the Owner of the Vehicle?
Vehicle Owner Information
First Name
Last Name
Phone#
Address
City
State
Zip
Occupants & Injuries
Were you the driver at the time of the accident?
Vehicle Driver Information
First Name
Last Name
Phone#
Address
City
State
Zip
Were there any witnesses to the accident?
Witness Information
First Name
Last Name
Phone#
Address
City
State
Zip
Were there any other occupants in your vehicle?
Number of occupants?
Occupant 1
First Name
Last Name
Age
Phone#
Occupant 2
First Name
Last Name
Age
Phone#
Occupant 3
First Name
Last Name
Age
Phone#
Occupant 4
First Name
Last Name
Age
Phone#
Were you or any passenger injured?
Number of occupants injured?
Driver
Occupant 1
Occupant 2
Occupant 3
Occupant 4
Damage & Accident
When did the accident occur?
Date
Time
Where did the accident occur?
Name of business
Address
City
State
Zip
Describe the damage to the vehicle or property
Explain how the accident happened. Give full account; stating speed and direction of each car:
Signature & Documents
TERMS OF ACCEPTANCE: I, the requestor of this claims request form, warrant the truthfulness of the information provided in this request.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Upload two written estimates for the repair of damages being claimed. For total loss or damages less than $2,000.00 you may provide just one estimate.
Photographs of the damage are recommended to assist in the review of your claim.
BY CHECKING THIS BOX, I AM ELECTRONICALLY SIGNING AND DATING MY APPLICATION.
Oak Harbor Claim#
Upload Documents:
To select consecutive images/documents, click the first item, press and hold down SHIFT, and then click the last item.
To select nonconsecutive images/documents, press and hold down CTRL, and then click each item.
Files to upload:
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Almost there!
Thank you! We have gathered all the required data to submit your claim.
Please click the 'Submit' button to create your claim
or click 'Previous Step' to go back and review your information before submission.