Auto

Auto Incident

Were you or one of your employees involved in an auto accident? Complete the below form to the best of your ability and an InterWest property and casualty claims professional will contact you as soon as possible but not more than one business day. If this is a claim involving major injuries or death, see the Emergency Claim Reporting Instructions under the Submit A Claim page. We ask you complete the form with the available information, however, if you do not have the information or it doesn’t apply simply leave it blank. Let our experience guide you!
InterWest Account Name*
InterWest Policy Number
InterWest Account Address
Street Address Address Line 2 City State ZIP Code
Claim Contact Name*
First Last
Contact Email*
Contact Phone*
INCIDENT INFORMATION
Describe the Incident
Date of Accident*
MM slash DD slash YYYY
Time of Accident

: Hours

Minutes

AM/PM
Accident Location
Street Address City State ZIP Code
Police Report
- Yes
- No
Responding Agency
Report Number
Insured Vehicle and Driver Information
Year
Make
Model
VIN
Insured Driver Name
First Last
Insured Driver Phone Number
Was another vehicle involved?
- Yes
- No
Other Party Vehicle And Driver
Year
Make
Model
License Plate Number
Other Party Name
First Last
Phone
Address
Street Address City State ZIP Code
Name of Other Parties Insurance Company
Other Parties Insurance Policy Number
Other Parties Damages
Was anyone injured in this accident?
- Yes
- No
Injuries
Injured Party #1 Name (enter if applicable)
First Last
Injured Party #2 Name (enter if applicable)
First Last
Injured Party #3 Name (enter if applicable)
First Last
Describe the Injuries
Were there any witnesses?
- Yes
- No
WITNESS/PASSENGER INFORMATION
Witness Name
First Last
Witness Phone Number
Witness #2 Name
First Last
Witness # 2 Phone (if applicable)
Witness #3 Name (Enter if applicable)
First Last
Witness #3 Phone (Enter if applicable)
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Please attach a copy of photos or any other information obtained at the scene of the accident.
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Auto Incident

INCIDENT INFORMATION

Insured Vehicle and Driver Information

Other Party Vehicle And Driver

Injuries

WITNESS/PASSENGER INFORMATION

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