Automobile

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automobile claim

Policy Number *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone *

Secondary Phone *

Best Time to Call *

Morning Afternoon Evening

Preferred Method of Communication *

Phone Email

Email *

Incident Overview

What was the date of the incident? *

What vehicle was involved? *

Was another vehicle involved? *

Cause of loss *

Describe, if other cause of loss: *

How severe was the damage? *

Is the vehicle driveable? *

Describe the incident *

Submit

Contact Information

Lonnie Short
Short Agency, Inc
107 Ditto Street
Archbold Ohio 43502

419-445-6846 Office
419-445-5103 Fax
419-583-9567 Cell
lonnie.s@shortagency.com

Terry Short
Short Agency, Inc
1398 N. Shoop Ave.
Wauseon Ohio 43567

419-335-9507 Office
419-335-2327 Fax
419-583-9571 Cell
terry.s@shortagency.com

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