File A Claim | First Chicago Insurance

Person Submitting Auto Claim

Name

Home Phone

Cell Phone

Yes, I consent to having First Chicago Insurance Company contact me about my claim via SMS/text messaging.
No, I DO NOT consent to having First Chicago Insurance Company about my claim to contact me via SMS/text messaging.

Policyholder

Policy Number

Name

Address

City

State

ZIP Code

Home Phone

Business Phone

Cell Phone

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Vehicle

Year

Make

Model

Driver

Name

Address

City

State

ZIP Code

Home Phone

Business Phone

Cell Phone

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Date of Accident

Time of Accident

Location of accident

How did the accident happen?

Was vehicle used with owner's permission?
Yes No

Is the vehicle drivable?
Yes No

Was your vehicle stolen?
Yes No

Was the theft or accident reported to the Police?
Yes No

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Was there any damaged property?
Yes No

Add Property

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Were there any injuries?
Yes No

Add Person

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Were there any witnesses?
Yes No

Add Person

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Were there any occupants of insured vehicle?
Yes No

Add Person

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