Claim Report

Auto Loss Claims Form

Claim Reporting Instructions 1. Items with * must be completed. Please complete as much of the questionnaire as possible. Upon completion, please click the blue SUBMIT button . 2. Leave the information you do not have blank. 3. Send any additional information or documents related. 4. Fax or email additional pages (if applicable) to 714-546-4457 or Please use a cover page and put attention Claims Dept.

Step 1 of 5