Automobile Claim Report

If you are reporting an Automobile Claim, please print and review this information first:

Company Reporting: To report your claim directly to your Insurance Company, use the information provided here:

IRMS Reporting: To report an Automobile Claim to IRMS, please complete this form and click “Submit”.

If you need assistance, please contact your Client Service Manager.

Contact Information
Client Name
Contact Name
First Last
Name of Business
Phone Number
Email Address
General Information
Date of Accident
MM slash DD slash YYYY
Location of Accident
Description of Accident
Responding Authorities
Responding Authorities Report Number
Driver of Your Vehicle
Driver's Full Name
First Last
Driver's Phone Number
Your Vehicle
Titled Owner Full Name
First Last
Vehicle Information
Vehicle Make Vehicle Model Vehicle Body Type Vehicle Identification Number
Description of Vehicle Damage
Driver of Other Vehicle
Other Driver's Full Name
First Last
Other Driver's Phone Number
Other Driver's Insurance Company and Policy Number
Other Driver's Vehicle Year
Policy Number
Other Driver's Vehicle
Make Model Body Type
Additional Comments
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Contact Information