Personal Automobile Claim

Automobile Loss Notice

NO COVERAGE OF ANY KIND IS BOUND BY
SUBMITTING INFORMATION VIA THIS ONLINE FORM.

Completion of this form does not constitute an actual claim, but serves to notify your agent of an existing loss or claim.

By completing this form, you are acknowledging your understanding of and agreement with these terms.
 
Your full name:
(as listed on policy now)
Your email address:
Daytime telephone number:
Description of Loss:
Time & date of accident/claim: Time AM PM
Date
Location of accident:


Description of accident:
Police notified? Yes No
Were you ticketed?

Yes No

If you received a ticket, what was it for?
Driver name:
Last four digits of VIN#:
Year:
Make:
Model:
Any additional information not requested above:
Additional information will be requested
upon receipt of this notice.
Also in Claims

FORREST SHERER
CLAIMS CENTER
24 N. 6th St.
Terre Haute, IN

If you have a claim and are having difficulty contacting your carrier, please contact us.
ph. 812.232.0441
fax 812.232.0926

If you prefer, report your claim to our office by clicking here.


   
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Forrest Sherer Insurance, 24 N. 6th Street, Terre Haute, Indiana 47807 - 812-232-0441