(208) 322-3473 stan@hartleyonline.com

Vehicle Claim Submission

Please answer as many questions as you can with the most accurate information available to you.
If you are not contacted within 2 business days after submitting this claim please contact Hartley Insurance or your insurance company directly by phone.


PERSONAL
INFORMATION
Your
name:		 First:

Last:
E-Mail
address:

Phone
numbers:		 Daytime:

Evening:

Fax:

How
would you prefer to be contacted?

Phone

Fax

Mail

E-mail
If
you would prefer to be contacted by phone,
please let us know the best time to call.

Address:

City:

State:

Zip
code:


Best time to contact
you:

Time
and Date of claim:

 


AUTOMOBILE INSURANCE
CLAIM
Location
of Accident

Insured
Vehicle :		 Owner:

Driver:

Other
Vehicle :		 Owner:

Driver:

How
would you prefer to be contacted
regarding your change?

Phone

Fax

Mail

E-mail
Other
party’s Name

Other
party’s Address:

City:

State:

Zip
code:

Were
police notified:

yes

no
Report
number:

Who
was cited?
Name
of any witness:
Was
anyone injured?
yes

no
What
happened?

 

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