File Automobile Claim

automobile claim

* Indicates required field

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

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Contact Information

Office Address
107 Ditto Street
Archbold, OH 43502
Contact
419-445-6846 Office
419-445-5103 Fax
zach.p@shortagency.com

Types of Insurance

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