First Notice of Loss Intake Form - Streamline

New or Existing Claim

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Please note a red asterisk is a required field. Please verify all fields with a red asterisk are complete in order to process your submission. Thank you.

Are you reporting a new claim? *

Please Select: Yes No

Are you looking for a claim status update? *

Please Select: Yes No

What is the Maryland Auto Insurance claim number?

Our claim numbers start with V

What is the Maryland Auto Insurance Policy Number?

Our Policy Numbers start with two letters and four digits

Date of Loss

Name of Claim Adjuster (if applicable)

Your Name*

First Name

Last Name

Preferred Contact Method?*

Phone Number? E-mail

Email Address:

Phone Number:

Enter phone number without dashes - XXXXXXXXXX

Any additional information?

Do you have documents you need to upload?

Please Select: Yes No

Please upload: No File Chosen

File uploads may not work on some mobile devices.

Files Accepted: jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx

Please upload: No File Chosen

File uploads may not work on some mobile devices.

Files Accepted: jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx

Please upload: No File Chosen

File uploads may not work on some mobile devices.

Files Accepted: jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx

Please upload: No File Chosen

File uploads may not work on some mobile devices.

Files Accepted: jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx

Who Are You?

Please note a red asterisk is a required field. Please verify all fields with a red asterisk are complete in order to process your submission. Thank you.

Role:*

Your Name:

First Name

Last Name

Your Phone Number

Enter the phone number without dashes - XXXXXXXXXX

Name of Law Office:

Law Office Address:

Address Line 1

City

State

ZIP Code

Law Office's Phone Number:

Enter phone number without dashes - XXXXXXXXXX

Adverse Insurance Company's Name:

Letter of Representation: No File Chosen

File uploads may not work on some mobile devices.

Claim Number:*

Contact Phone Number:

Enter phone number without dashes - XXXXXXXXXX

Contact E-mail Address:

Type of claim?

Date of Accident *

Time of Accident *

Location of Incident

Address Line 1

Address Line 2

City

State

ZIP Code

Brief Summary of Incident*

Please enter what occurred

Number of Vehicles Involved

1 2 3 or more

Policyholder Information

Please note a red asterisk is a required field. Please verify all fields with a red asterisk are complete in order to process your submission. Thank you.

Policy Number:

Policyholder Address:

Address Line 1

City

State

ZIP Code

Policy Holder Name:

First Name

Last Name

Policyholder E-mail:

Phone

Enter phone number without dashes - XXXXXXXXXX

Policyholder Phone Number:

Enter phone number without dashes - XXXXXXXXXX

Insured Vehicle Year:

Insured Vehicle Make:

Insured Vehicle Model:

Tag Number/State of Tags

Tag Number/State of Tags *

Vehicle Identification Number:

Was the insured the driver of the vehicle?

Please Select: Yes No

Driver at time of incident:

First Name

Last Name

Driver Address:

Address Line 1

City

State

ZIP Code

Driver's Phone Number:

Enter the phone number without dashes - XXXXXXXXXX

Relationship to the insured?

Did the driver of the vehicle have the owner's permission to use the vehicle?

Please Select: Yes No Unknown

Description of Vehicle Damage:

Other Parties Information:

Please note a red asterisk is a required field. Please verify all fields with a red asterisk are complete in order to process your submission. Thank you.

Other Party:

First Name

Last Name

Address

Address Line 1

City

State

ZIP Code

Phone

Driver's License Number:

State Driver's License is Held in:

Date of Birth:

Year:

Make:

Model:

Insurance Information:

Please included: Policy number and/or claim number.

Color:

Tag Number/State of Tags

Description of Vehicle Damage:

Any additional vehicle information?

Please list all vehicle and owner contact information:

Is the vehicle drivable?

Please Select: Yes No

Name of Business (if applicable)

Vehicle location:

Address Line 1

City

State

ZIP Code

Phone Number:

Enter the phone number without dashes - XXXXXXXXXX

Was this person the driver?

Please Select: Yes No

Name

First Name

Last Name

Phone Number:

Enter the phone number without dashes - XXXXXXXXXX

New or Existing Claim

Who Are You?

Policyholder Information

Incident Information

Other Party's Information:

Other Parties Information: