Auto Incident Form

Insured Detail

Accident Detail

Other Party Detail

Injured Detail



(will also receive copy of incident report)

If there are any questions, please contact your P/C Claim Representative at, 800-292-5421 or by fax 517.482.0800

If submitted properly, a confirmation email will be sent to you with a reference ID number. It is important to keep that reference ID number in case you have questions.

Submit your form