Claim Form

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ACCIDENT INFORMATION

Accident Date
MonthSelect Month / DaySelect Day / YearSelect Year
Time of Accident
TimeSelect time / AM ☐ / PM☐

Accident location

Address
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CityClick here to enter text. / StateSelect State / Zip CodeClick here to enter text.
Description of Accident
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Were police called ? / YES ☐ / NO ☐
If, yes, Department NameClick here to enter text.
Report NumberClick here to enter text.
Were any tickets issued by the police, If so, please describeClick here to enter text.

Injury information

Were there any injuries? / YES ☐ / NO ☐ / Don’t know ☐
Did an ambulance come to the scene? / YES ☐ / NO ☐
Was anyone transported to hospital? / YES ☐ / NO ☐
Was the injured party….(check all that apply) / In Policyholder vehicle ☐ / In other vehicle ☐ / Pedestrian/bicyclist/other ☐
Extent of injuries, if known
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Provide name(s), address(es), phone no(s) and the name of the medical facility
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POLICYHOLDER INFORMATION

AMIC Policyholder nameClick here to enter text.
Contact name (Last, First, MI) / Last Click here to enter text. / First Click here to enter text. / MI Click here to enter text.
Policy NoClick here to enter text.
Policyholder Street
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City Click here to enter text. / State Select State / Zip CodeClick here to enter text.
Phone NoClick here to enter text. / ExtClick here to enter text.
Policyholder Vehicle Information
YearClick here to enter text. / MakeClick here to enter text. / ModelClick here to enter text.
VINClick here to enter text. / License Plate NoClick here to enter text.
If applicable, was policyholder vehicle damaged / YES ☐ / NO ☐
If yes to above, area of damage
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Photos taken / YES ☐ / NO ☐
If yes to above, click below to upload pictures

Name of driver (Last, First, MI) / Last Click here to enter text. / First Click here to enter text. / MI Click here to enter text.
License No.Click here to enter text.
Driver Phone NoClick here to enter text.
Number of & Name(s) of passengersClick here to enter text.
OTHER VEHICLE INFORMATION
YearClick here to enter text. / MakeClick here to enter text. / ModelClick here to enter text.
License Plate NoClick here to enter text.
Area of damage
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Name of Vehicle Owner (Last, First, MI) / Last Click here to enter text. / First Click here to enter text. / MI Click here to enter text.
Street Address or PO Box
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City Click here to enter text. / State Select State / Zip Code Click here to enter text.
Owner Phone noClick here to enter text.
Vehicle Owner Insurance CompanyClick here to enter text. / State Select State / Zip Code Click here to enter text.
Policy noClick here to enter text.
DRIVER INFORMATION
Name of Vehicle Driver (Last, First, MI) / Last Click here to enter text. / First Click here to enter text. / MI Click here to enter text.
Street Address or PO Box
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CityClick here to enter text. / State Select State / Zip Code Click here to enter text.
Driver Phone noClick here to enter text.
Drivers License NoClick here to enter text.
Name(s) of Passengers
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Vehicle Driver Insurance CompanyClick here to enter text.
Policy noClick here to enter text.
WITNESS INFORMATION
Were there any witnesses present? / YES ☐ / NO ☐
If yes, please provide name(s), address(es and phone number(s)
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OTHER INFORMATION
If something other than a vehicle was damaged, please describe other important claim information or comments
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Name of person completing report
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E mail address Click here to enter text.

Phone No Click here to enter text.