Auto insurance claim form
An auto insurance claim form captures the essential details an adjuster needs to investigate a car accident or damage claim — the policyholder's info, the date and time of the incident, where it happened, what happened, and photos of the damage.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
A date and time field captures the exact moment of the incident
Adjusters cross-reference date and time with records, traffic cameras and witness statements.
A location text field is clearer than a generic "address" field
Incident locations vary — parking lot, highway, intersection — and text is more flexible than a structured address form.
This one uses file uploads, which is a paid feature — you can build and edit it on the free plan, but saving it needs an upgrade.
No card required.
Auto Insurance Claim Form
Live previewHow to build this form
8 steps in the editor.
- Add text and email fields for policyholder name and email.
- Add a phone field for policyholder contact information.
- Add a text field for insurance policy number.
- Add date and time fields for the incident.
- Add a text field for incident location (street address, intersection, parking lot, etc.).
- Add a required textarea for description of what happened.
- Add an optional textarea for other party's information (name, phone, address).
- Add an optional file field for damage photos.
Fields in this form
10 fields, using 7 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Policyholder name | Short text | Yes |
| Policy number | Short text | Yes |
| Email address | Yes | |
| Phone number | Phone | Yes |
| Date of incident | Date | Yes |
| Time of incident | Time | Yes |
| Location of incident | Short text | Yes |
| What happened? | Long text | Yes |
| Other party's information (optional) | Long text | Optional |
| Photos of damage (optional) | File upload | Optional |
What goes wrong with this form
Specific to a auto insurance claim form, not general advice about forms.
Using text instead of date and time fields
Text entries like "Friday morning" are vague. Date and time fields give the adjuster exact timing for the incident.
Not collecting damage photos
Photos are the fastest way for an adjuster to assess damage severity and make a liability determination.
Forgetting to ask when the incident occurred
Date and time are essential for the adjuster to investigate. Without them, claims are hard to verify.
Questions about this form
Does this form process or approve my claim?
No. This form is an intake tool. An adjuster will review the information and contact you to investigate and make a decision.
Can I attach multiple photos of the damage?
Yes. Use the file upload field to attach one or more photos of the vehicle damage from different angles.
What if the other driver did not provide their information?
Leave the "other party" field blank if you do not have their details. The adjuster can investigate further using police reports or witnesses.
This one uses file uploads, which is a paid feature — you can build and edit it on the free plan, but saving it needs an upgrade.
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