Needham Auto Claim Form | Insuring Massachusetts

1) Vehicle Owner Information:
Name
Address
Street Address City State ZIP Code
Phone Number
When can you be reached?
Type of Vehicle
Color of Vehicle
License Plate Number
2) Operator Information
Name
Address
Street Address City State ZIP Code
Phone Number
Operator License Number
Operator Date of Birth
3) Accident Information:
Date of Accident
Time of Day

: HH

MM
Street occurring on
Town and State
Description of Accident
Describe damage to your vehicle
Is your car drivable?
- Yes
- No
If not, where will it be to have an appraiser view the damage, within the next 2 business days?
Did police com to scene?
- Yes
- No
What police department?
Did police take a report or issue a citation?
- Yes
- No
4) Other Vehicle Information:
Name
Address
Street Address City State ZIP Code
Owner Phone Number
Driver Name
Driver Address
Street Address City State ZIP Code
Driver Phone Number
Type of Vehicle
Registration Number
Insurance Company
What was damage to other vehicle?
Was anyone injured?
Additional Comment
Name
This field is for validation purposes and should be left unchanged.

1) Vehicle Owner Information: