Claims

Auto Claim Form

We will be happy to assist you with your auto claim. All you need to do is fill out the form below, then click "Submit Request" at the bottom. One of our agents will personally review your information and contact you promptly about the claim.

Entries marked with an asterisk (*) are required.

Your name:*

Insured Information

Insured's name:*
Street address:*
City:*
State:*
Zip Code:*

Accident / Insured Loss Information

Date of loss:*	(mm/dd/yyyy)
Time of loss:*
Type(s) of loss:*	Collision
	Comprehensive
	Glass
	Towing
	Liability
	Medical payments
Location of accident:*
Description of accident:*
Insured vehicle damage:
Insured vehicle drivable?:	Yes No
Insured vehicle loc. (with phone #):
Driver of insured vehicle:*
Relationship of driver to insured:*
Insured vehicle driver injuries:
Witnesses / Passengers:
Authority contacted & report #:*
Insured vehicle driver cited?:*	Yes No

Claimant Information

Claimant's name:
Street address:
City:
State:
Zip Code:
Phone (include area code):
Insurance company:
Policy number:
Damage to claimant property: (If vehicle, include year, make, model)
Location of claimant property:
Injuries: (Name / details of each party)
Witnesses / Passengers:

When to Report Claim

Report claim:*

Now Wait for estimates

Contact Information

Please contact me via (select one or more options):*
Phone (include area code):
FAX (include area code):
E-Mail:
Postal mail:
Street:
City:
State:
Zip:

Other

Questions, comments, or special requests:

Submit Request

NOTE:

The information you submit will be transmitted from this Web site to our staff via email through the Internet. Additionally, information you enter will be transmitted from your computer to our Web site in un-encrypted form. We believe that this transmission is unlikely to be intercepted, but we cannot guarantee privacy of the information you submit while it is passing through the Internet. If you do not wish to submit this form from the Web, please feel comfortable contacting us by telephone, FAX or other postal mail, and we will be happy to respond to you in that way.

Contact Us

FirstChoice Insurance Agency, Inc.
338 Pearl Ave.
Oshkosh, WI 54903-0766
(920) 235-3450, Toll free: (800) 368-7536, FAX: (920) 232-8731
E-Mail: mail@firstchoiceinsurance.biz