Auto Insurance - Report a Claim

Please note: Submitting a claim at this web site does not confirm coverage or authorize payment. A claims representative will verify coverage and contact you to complete the claims process.

If more than 2 people are involved, please call our agency directly to report the claim.
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:
Where is your car now?
Persons Injured:
Name and address:
Phone number:
Nature of Injuries:
Describe Other Car:
Year/Make/Model:
Owner's name/address:
Owner's PH#
Driver's name/address:
Driver's phone number:
Describe damage:
Insurance agent/company:
   
 
 Describe What Occurred:
   
Comments and/or Other Information:
           
If you have not received a response from us within one business day, please contact us again.  Thank you.


Hall-Green Agency, Inc.
146 North Depeyster Street  •   Kent  OH  44240
(330) 673-5873   •  Fax: (330) 673-1350