Contact Us  |  April 25, 2017

Auto Claim

To expedite the processing of your claim, please complete this notice with as much information as you have available.
Contact Information
Name: *
Daytime Phone Number: *
Fax Number:
Email:
Best Time to Call: *
Insured Information (for Business Customers only)
Company Name:
Address:
City:
State:
Zip Code:
Accident Information
Date of Accident: *
Accident Location: (Please indicate street/intersection/location, city, and state.) *
Brief Description of Accident: *
Police Contacted? * Yes  No
If so, Which Police Department:
Report Number (if available):
Insured Driver Information
Is the driver involved in the accident the same as the contact noted above? If no, please complete the information below. * Yes  No
Name:
Daytime Phone Number:
Insured Vehicle Information
Year: *
Make: *
Model: *
VIN#:
Damage to Vehicle: *
Where Can Vehicle Be Seen?
Other Driver Information
Name:
Address:
City:
State:
Zip Code:
Daytime Phone Number:
Other Vehicle Information
Year:
Make:
Model:
Damage to Other Vehicle:
Where can vehicle be seen?
Injury Information
Were injuries sustained? Yes  No
If yes, please describe:
Witness Information
Please enter name, address and daytime phone numbers for each witness.
Additional Comments
Please enter any additional comments you feel we need about this claim.
* = Required Field
You will be contacted by a representative of Marsh & McLennan Agency LLC (formerly Kinker-Eveleigh Insurance Agency) within 24 hours of our receipt of this form. If you do not hear from us, please call our office at (513) 248-4888. Please note that submission of this form does not constitute notice of a claim to either Marsh & McLennan Agency or your respective insurance company until confirmed by Marsh & McLennan Agency or your insurance company.