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Formerly Galen Smith Insurance
   
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  Home Owners     Auto     Life - Disability
   Auto Insurance - Report a Claim 
To report a claim by phone, please visit our Contact page.
   
Policy Number:
Your Name:
Contact Person:
Whom should the adjuster
contact about repairs?
Name:
Home phone:
Work phone:
Email address:

Authority Contacted:
Police department:
Report number:

Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Describe, if other cause of loss:

Your Damaged Car:
Year/Make/Model:
Driver's name/address:
Driver's phone number:
Describe your damage:
Is the car driveable?
If not, where is it located?

Persons Injured:
Name and address:
Phone number:
Nature of injuries:

Describe Other Car:
Year/Make/Model:
Owner's name/address:
Owner's phone number:
Driver's name/address:
Driver's phone number:
Describe damage:
Insurance agent/company:

Describe What Occurred:
Comments and/or Other Information:
 
 
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