Auto Insurance - Report A Claim

Reporting a claim at this website does not confirm coverage or authorize payment.  We will contact you personally to review your claim.

Policy Number:
Your Name:
Contact Person:
Whom should we call to settle your claim?

Name:                     
Phone:                          
Work Phone:           
Cell Phone:             
Best Time to Call:    
Email:                            

Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Authority that you contacted:
Police/Fire dept:
Report number:
Describe Your Damages/Loss:
Your Damaged Vehicle:

Year/Make/Model:                   
Driver's Name/Address:            
Driver's Phone Number:            
Describe Damage to Your Vehicle: 

Where is your car located?      

Injured Persons:
Name/address
Phone number:
Nature of injuries:
Cause of injuries:
Witnesses/Passengers:   Yes      No
If yes, please list:
Describe Other Vehicle: Year/Make/Model:                   
Driver's Name/Address:            
Driver's Phone Number:            
Owner's Name/Address:           
Owner's Phone Number:           
Describe Damage to Vehicle: 


Insurance Company/Agent?      
Three or More Vehicles Involved? Yes   No
Describe the Incident that Occurred:
   
Other Information:

We will contact you personally within one business day.  If you have not heard from us please call our office.

 

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  Stahl Stoller Meyer Insurance Center: Paulding Location: 419-399-3777 • Van Wert Location: 419-232-4776

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