Colton, Downey & Associates, Inc.


	1122 Veterans Drive, Jacksonville, IL 62650 217-243-8000 FAX 217-243-3301 109 Morse, Roodhouse, IL 62082 217-589-5890 FAX 217-589-4925

Home, Auto, Boat, Mobilehome, Motorcycle, Rental Dwelling, and more.

As Business Grows, and You Start To Have Insurance Woes, Call The Pros

24 Hour Claim Services

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AUTO ACCIDENT CLAIM FORM

Fill out the form online below with information relating to your claim: (Some lines may not be related to your claim)


Driver Information
Driver's Name:
Insured's Name:
Date of Accident:
Location of Accident: (Street, City, State)
Your Vehicle Information
Year:
Make:
Model:
VIN#:
Area of Damage to Vehicle:
Drivable:	Yes No
If Not Drivable, where can Vehicle Be Seen:
What Happened:

Other Driver Information
Driver Name:
Home Phone:
Work Phone:
Address:
Insurance Company:
Agent:
Other Driver's Vehicle Information
Year:
Make:
Model:
VIN#:
Area of Damage to Vehicle:
Drivable:	Yes No
If Not Drivable, where can Vehicle Be Seen:
Other Drivers Injuries
Any Injury to Driver or Passengers of Either Vehicle:	Yes No
If Yes:
Name of Injured Person:
Describe Injury:

Name of Injured Person:
Describe Injury:
Authority At Scene:
Case Number:
Were Police Called:	Yes No
Was a Ticket Issued:	Yes No
To Which Driver:
Witnesses:
Name:
Address:
Home Phone Number:
Work Phone Number:

Additional Information:


We will be in contact with you on the next business day.


	Click here to find the NADA value of your vehicle.