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Accident Information
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Person Submitting Auto Claim
Name
Home Phone
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I consent to having American General Insurance Company contact me about my claim via SMS/text messaging
No,
I DO NOT consent to having American General Insurance Company about my claim to contact me via SMS/text messaging.
Policyholder
Policy Number
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Vehicle
Year
Make
Model
Driver
Name
Address
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Florida
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Accident Information
Date of Accident
Time of Accident
Location of accident
How did the accident happen?
Was vehicle used with owner's permission?
Yes
No
Is the vehicle drivable?
Yes
No
Was your vehicle stolen?
Yes
No
Has your stolen vehicle been recovered?
Yes
No
Was the theft or accident reported to the Police?
Yes
No
Police Report #
Accidedantal
Accidedantal Multi-Image Upload
Accidedantal Multi-Video Upload
FIR Copy File Upload
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Damage
Was there any damaged property?
Yes
No
Property # 1
Property Owner
Name
Address
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State
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Connecticut
Delaware
Florida
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Hawaii
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Louisiana
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Maryland
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Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
Home Phone
Business Phone
Cell Phone
List of Damages
Was there any damaged property?
Yes
No
Name of insurance company
Policy Number of other insurance
Add Property
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injuries
Were there any injuries?
Yes
No
Injured# 1
Name
Address
City
State
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Colorado
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Delaware
Florida
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Hawaii
Idaho
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Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
Home Phone
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Cell Phone
List of Injuries
Location
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Policyholder Vehicle
Other Vehicle
Other
Add Injured
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witnesses
Were there any witnesses?
Yes
No
Witness# 1
Name
Address
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
Home Phone
Business Phone
Cell Phone
Add Witness
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Occupant
Were there any occupants of insured vehicle?
Yes
No
Occupant# 1
Name
Address
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
Home Phone
Business Phone
Cell Phone
Add Occupant
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