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Phone Number

Type of Claim

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Trim Level (SE, SE, LE, Base, etc)

Approximate mileage on accident date

Date of Accident

State where the accident happened

Estimated repair costs

Any prior accidents or repairs?

If yes, estimated repair cost of the previous accident

Are you leasing your vehicle? (Vehicle will be turned back in on a set date)

Yes No

Name of your insurance company?

Name of at-fault insurance company?

File Upload (repair estimate, supplement, final bill, total loss valuation, etc)

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