AGIS Insurance Center - Automobile Claim Report

Brookfield Business List

Automobile Claim

Emergency Claim Reporting

Use the form below to report claims to our office. Claim reports will be submitted to your insurance company by our office the following business day.

If this is an emergency, after our office hours or during a weekend or holiday, please report your claim directly to your insurance company claim office:

Emergency Claim Reporting Numbers

Links to Insurance Company Websites

AUTOLOSS NOTIFICATION

POLICY HOLDER INFORMATION
Please be sure to supply all if your contact information so we may promptly contact you after receiving this notification.
Name of Insured:
Address:
Phone #:	Work Home
Email:

TIME AND LOCATION OF ACCIDENT/LOSS

Time & Date of Loss

Time

a.m.
p.m.

Date

Location of Accident:
(Number, Street, Intersection, etc.)

Description of Accident:

POLICE NOTIFICATION
Were the Police Notified?	Yes No
What Authority?
Were You Ticketed?	Yes No
If Yes, what for?

YOUR VEHICLE INFORMATION
Damage to your vehicle?	Yes No
If Yes, describe:
Where can the vehicle be seen:
What vehicle were you driving?	Yr. Make Model
License Plate #:	State
Is this your vehicle?	Yes No
If No, were you using it with permission?	Yes No Please explain below:

OTHER DRIVER INFORMATION
Name:
Address:
Phone:	Work Home
Vehicle:	Yr. Make Model
Driver's License #:	State
License Plate #:	State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

INJURIES, WITNESSES, ETC.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers:	(Please include Name, Address and Phone #)

POLICE REPORT INFORMATION
Reported by:
Title (if any):
Date:

ADDITIONAL COMMENTS

Please give any additional comments regarding this Loss Notice.

DISCLAIMER:

I understand that by completing this form it does not constitute an actual
claim, but is rather a notification to my agent of an existing loss or claim,
and may help expedite the claim process once I have filed.

One of our representatives will respond to your submission as soon as possible.

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AGIS Insurance Center, Inc.
165 Bishops Way Suite 120
Brookfield, WI 53005
Phone: 262-641-9800
Email:AGIS.HOME@agisins.com

Hours of Operation

Monday - Friday 8:30am to 5:00 pm CST
Or by Appointment