Report a Claim

POLICY

* Do you have a Traders Insurance Policy Number to start the claims process Yes No * Traders Insurance Policy Number

CLIENT INFORMATION

* Who is submitting this claim? Traders Insurance Policy Holder Claimant Against Policy Holder Insurance Carrier Attorney Other * What is your prefered language? Select One English Spanish Other * Name of person reporting claim

Loss Information

* Please explain how this loss or accident occurred Police Department Police Report Number or Case Number

LOCATION OF LOSS/ACCIDENT

* Intersection/Street/Freeway

Traders Insurance Policy Holder Information

Street Address

Traders Insurance Policy Holder Driver Information

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Who is the vehicle's owner? * Street Address Was this person Injured? Yes or No IF yes Please explain Injuries

Traders Insurance Policy Holder Vehicle Information

License Plate Number License Plate State Select state AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Describe Vehicle Damage Is the vehicle drivable? Yes No Where is the vehicle currently located? Please list the names of any passengers and their contact information Are any passengers Injured? Yes or No IF yes: Who? Please explain Injuries Were additional vehicles involved? Yes No

Other Vehicle Driver Involved in Accident

Who is the vehicle's owner? Street Address Was this person Injured? Yes or No IF yes Please explain Injuries

Other Vehicle Involved in Accident

License Plate Number License Plate State Select state AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Describe Vehicle Damage Is the vehicle drivable? Yes No Where is the vehicle currently located? Please list the names of any passengers and their contact information Are any passengers Injured? Yes or No IF yes: Who? Please explain Injuries

Property Damaged

Please describe any other property damaged (e.g. mailbox, street sign, ect.)

Injured Persons

Are any of the above injured parties seeking treatment? Yes or No, If Yes where?

Witnesses

Please list the names, addresses, and phone numbers for all witnesses