File A Claim

You may complete a claim online on the form below. In addition, claims can be filed via our Alinsco Mobile App for the fastest service. Feel free to contact our claims line 24/7 at 1-877-437-5007

Basic Information

Company Name:

Your Name

Phone Number

Alinsco Policy #

Loss Date

Loss Time

Insured - Alinsco Policy Holder

First Name

Middle Init.

Last Name

Home Phone

Work Phone

Street Address

City

State

Zip

Driver

First Name

Last Name

Date of Birth

Driver License #

Relationship to Insured

Home Phone

Other Phone

Street Address

City

State

Zip

Driver Insurance Company

Were You Injured?

Where Were You Taken?

Doctor's Name

Description of Injury

Number of Passengers

Permission to Use Vehicle?

Seat Belt Worn?

Air Bag Activated?

Ambulance to Hospital?

Insured's Vehicle Description

Year

Make

Model

Color

License Plate #

License Plate State

VIN Number

Point of Impact

Vehicle Drivable?

Vehicle Towed?

Repair Estimate

List all damaged areas of vehicle due to this incident

Insured's Vehicle Current Location

Name of Establishment

Contact Person

Phone

Street Address

City

State

Zip

Claimant - Not An Alinsco Policy Holder

First Name

Middle Init.

Last Name

Home Phone

Work Phone

Street Address

City

State

Zip

Driver

First Name

Last Name

Date of Birth

Driver License #

Relationship to Claimant

Home Phone

Other Phone

Street Address

City

State

Zip

Driver Insurance Company

Where You Injured?

Where Were You Taken?

Doctor's Name

Description of Injury

Number of Passengers

Permission to Use Vehicle?

Seat Belt Worn?

Air Bag Activated?

Ambulance to Hospital?

Claimant's Vehicle Description

Year

Make

Model

Color

License Plate #

License Plate State

VIN Number

Point of Impact

Vehicle Drivable?

Vehicle Towed?

Repair Estimate

List all damaged areas of vehicle due to this incident

Claimant's Vehicle Current Location

Name of Establishment

Contact Person

Phone

Street Address

City

State

Zip

Facts - Location of Loss

Address / Intersection

City

State

Description of Accident

Road Conditions

Speed Limit (MPH)

Police Report?

Location & Precinct

Case Number

Tickets Issued?

Issued Against

Type of Tickets

Injuries

Number of People Injured

Injured Person #1

First Name

Last Name

Phone

Birth Date (or Age)

Street Address

City

State

Zip

Description of Injury

This person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Injured Person #2

First Name

Last Name

Phone

Birth Date (or Age)

Street Address

City

State

Zip

Description of Injury

This person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Injured Person #3

First Name

Last Name

Phone

Birth Date (or Age)

Street Address

City

State

Zip

Description of Injury

This person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Note: Information on any additional injured persons will be taken when we contact you.

Witness Number 1

First Name

Last Name

Home Phone

Other Phone

Street Address

City

State

Zip

Witness Number 2

First Name

Last Name

Home Phone

Other Phone

Street Address

City

State

Zip