Policy Holder Information

First Name(*)
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Last Name(*)
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Address 1
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Address 2
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City
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State
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Phone Number
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E-mail
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Accident Information

Date
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Time - Hour:Min AM or PM)
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Location
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Description
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Injuries(*)
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Tickets(*)
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Your Vehicle Information

Vehicle(*)
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Driver's Name(*)
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Other Vehicle & Driver Information

Other Vehicle(*)
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Other Driver's Name(*)
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Finish & Submit

Disclaimer: I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed. If DG office is closed I understand this will not be reported until the next business day.

Agree & Submit

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