Home
Request a Quote
Contact Us
Forms | Claims
Coverages

Contact Information

Aegis Insurance Services, Inc
5755 North Point Parkway
Suite 44
Alpharetta, GA 30022

Telephone
Atlanta, GA Area:
(770) 360-5565
Toll Free:
(800) 582-6270
Fax
(770) 667 8348

Download the checklist of information required for a quote.

Auto/Truck Claim Reporting Form


Date:
*Requester Name:
*Company Name:
Email:

Insured's Information

Insured's Name:
Insured's Address:
Insured's Phone #:

Insured's Vehicle Information

Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN #:
Description of Damage:
Driver's Name:
Driver's Address:
License Number:
State:
Phone #:
Date of Loss:
Location of Loss:

Additional Information

Location of Loss:
Case # Assigned:
Were the police contacted?:

Description of Accident:

Other Comments:

Claimant #1's Information

Claimant's Name:
Claimant's Address:
Claimant's Phone #:

Claimant #1's Vehicle Information

Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN #:
Description of Damage:
Where can damaged vehicle be seen?:
Driver's Name:
Driver's Address:
License Number:
State:
Phone #:

Claimant #2's Information

Claimant's Name:
Claimant's Address:
Claimant's Phone #:

Claimant #2's Vehicle Information

Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN #:
Description of Damage:
Where can damaged vehicle be seen?:
Driver's Name:
Driver's Address:
License Number:
State:
Phone #:

Claimant #3's Information

Claimant's Name:
Claimant's Address:
Claimant's Phone #:

Claimant #3's Vehicle Information

Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN #:
Description of Damage:
Where can damaged vehicle be seen?:
Driver's Name:
Driver's Address:
License Number:
State:
Phone #: