What Makes Us Different Our People History Principles of Security Contact Us Locations Home Page Home Page Community and Industry Affiliations
Secured by SSL

Automobile Claim Form


…Providing claims service is the most important thing we do. (see our guiding principles)

We want to help you get things back to “normal” as quickly and fairly as possible.  We would
like to talk with you (336-945-3713) to help you through that process.  If you are in an emergency situation, you can click on your company’s website for 24 hour contact information.  You are also free to call John Wells at (336) 712-1069.

If you prefer, you are welcome to file through the following:


Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
How severe was the damage?
Required
Bodily Injury Liability
Required
Describe the incident.
Required
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.