Colton, Downey & Associates, Inc.


	1122 Veterans Drive, Jacksonville, IL 62650 217-243-8484 FAX 217-243-3301 109 Morse, Roodhouse, IL 62082 217-589-5890 FAX 217-589-4925

Home, Auto, Boat, Mobilehome, Motorcycle, Rental Dwelling, and more.

As Business Grows, and You Start To Have Insurance Woes, Call The Pros

24 Hour Claim Services

AUTO ACCIDENT CLAIM FORM

Fill out the form online below with information relating to your claim: (Some lines may not be related to your claim)


Driver Information
Driver's Name:
Insured's Name:
Date of Accident:
Location of Accident: (Street, City, State)
Your Vehicle Information
Year:
Make:
Model:
VIN#:
Area of Damage to Vehicle:
Drivable:	Yes No
If Not Drivable, where can Vehicle Be Seen:
What Happened:

Other Driver Information
Driver Name:
Home Phone:
Work Phone:
Address:
Insurance Company:
Agent:
Other Driver's Vehicle Information
Year:
Make:
Model:
VIN#:
Area of Damage to Vehicle:
Drivable:	Yes No
If Not Drivable, where can Vehicle Be Seen:
Other Drivers Injuries
Any Injury to Driver or Passengers of Either Vehicle:	Yes No
If Yes:
Name of Injured Person:
Describe Injury:

Name of Injured Person:
Describe Injury:
Authority At Scene:
Case Number:
Were Police Called:	Yes No
Was a Ticket Issued:	Yes No
To Which Driver:
Witnesses:
Name:
Address:
Home Phone Number:
Work Phone Number:

Additional Information:


We will be in contact with you on the next business day.


	Click here to find the NADA value of your vehicle.