West Virginia Insurance | Allegheny Insurance

Auto Loss Claim Form
Complete and submit the form below to make a claim on your auto insurance. Once submitted, the form will be e-mailed to our staff, and you will be contacted for confirmation.

GENERAL INFORMATION
Name:
Address:
City, State, Zip:
Daytime Phone #:
FAX #:
Evening Phone #:
E-Mail:
How would you like to be contacted?:		Daytime Phone Evening Phone E-mail FAX Mail
INSURED VEHICLE AND DRIVER INFORMATION
Make:
Model:
Year:
Driver's Name:		Name:
Relationship to Owner:
Used with permission?:		Yes No
ACCIDENT LOSS INFORMATION
Location of Accident (Include City):
Authority Contacted:
Report #:
Violations or Citations:
Description of accident and damage:
Describe any damage to other's property:
Other Party's Name:		Address: City, State, Zip Phone:
Was the driver or anyone in your vehicle injured?:		Yes No
Were anyone other parties injured?:		Yes No
First Injured Person:		Pedestrian Driver Passenger Address: City, State, Zip Phone:
Second Injured Person:		Pedestrian Driver Passenger Address: City, State, Zip Phone:
Third Injured Person:		Pedestrian Driver Passenger Address: City, State, Zip Phone:
Name of Witness:		City, State, Zip Phone:

Planning for risk requires vision. Managing risk requires a lasting relationship.

At Allegheny Insurance we consider our strength to be the personal service provided by our skilled and knowledgeable staff. Every member of our team works hard to ensure a personal and exceptional level of service with each client interaction.This is the Allegheny Difference. We encourage you to Meet our staff.