Claim Notification Form

Insured's Information

*First Name

*Last Name

*Phone Number

*Email

*Address 1

Address 2

*City

*State

Incident Details

Incident Date

Incident Time

Incident Location

Incident Description

Injuries

Tickets Issued

Your Vehicle

Your Vehicle Information

Driver's Name

Other Vehicle

Other Vehicle Information

Other Driver's Name

Agree & Submit

Disclaimer: I understand that this 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. If DG office is closed I understand this will not be reported until the next business day.

I understand and agree.