Automobile Claim Form

Did you have an accident? Do you have a claim to submit? You have come to the right place. Below you will find the Automobile Claim form. Yes you can fill it out right now!

Please complete the following automobile claim form as completely as you can.  If a particular question doesn’t apply to you or you don’t have the information just skip it and go to the next question.  Please pay particular attention to the data which advises us of where and when to contact you so we can get in touch with you.  Be sure to click the “Submit” button after completing the claim form.  For current customers inquiring into a current claim please email mzoladz@chaseins.com

  • Accident Information

  • :
  • Please give a brief explanation of the accident. Were police involved? Please list any information on the OV (other party)
  • Insured

  • Automobile Owner & Driver Information

  • If multiple vehicles are listed on your policy, please tell us which vehicle was involved with the accident.