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D.C. Metro 301.937.0400    Baltimore 410.792.4662   
Toll Free 877.567.3749

A U T O   I N S U R A N C E   C L A I M   F O R M 
I N S U R E D   P A R T Y
 Name:
 Address:
 City:
 State and Zip:
 Email  
 Day Phone:
 Evening Phone:
 Fax
D R I V E R
 Same as Insured Party:
 Name:
 Address:
 City:
 State and Zip:
 Home Phone:
 Work Phone:
 Age:
 Relationship to Insured:
 Vehicle Used with Permission?
V E H I C L E  
 Year:
 Make and Model:
W H E N   A N D   W H E R E
 Date of Accident:
 Day of Week
 Time:

 Location:
P R O P E R T Y   D A M A G E D
 Driver's Name:
 Address:
 City:
 State and Zip:
 Home Phone:
 Work Phone:
 Owner's Name:
 Address:
 City:
 State and Zip:
 Home Phone:
 Work Phone:
 Vehicle Year:
 Make and Model:
 V.I.N.
 License Plate Number:
 Describe Damage:
 Estimated Amount:
 Location of Car:
 Insurance Company Name:
P E R S O N S   I N J U R E D
 Name:
 Address:
 Home Phone:
 Work Phone:
 Age:
 Describe Injury: Seat Belts?
 Doctor:
 Hospital: Confined?
W I T N E S S  
 Name:
 Address:
 Home Phone:
 Work Phone:
P O L I C E  
 Were Police at the Scene?
 What department?
 Hit and Run?
 Speed:
 Direction:
 Number of Occupants:
D E T A I L S  

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P.O. Box 899  College Park, MD 20741
 410-792-4662 Baltimore | 301-937-0400 D.C. Metro | 301-937-5120 Fax
 Toll Free 1-877-567-3749

 ©2005 Joseph W. McCartin Insurance, Inc.