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Commercial Auto Claim Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Policy Information
Date & Time of Loss
Required
Carrier
Optional
Policy Number
Optional
Insured Information
First Name
Required
Last Name
Required
Date of Birth
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Primary E-Mail Address
Required
Contact Information
Contact Insured
Optional
First Name
Required
Last Name
Required
Primary Phone Number
Required
Mailing Address
Required
E-Mail Address
Required
When to Contact
Optional
Incident Overview
Location of Loss Street Address
Required
City, State, Zip
Required
Police or Fire Dept Contacted
Required
Describe Location of incident if not at specific street address
Required
Describe the incident
Required
Insured's Vehicle
Year
Required
Make
Required
Model
Required
VIN
Optional
Plate Number
Optional
Owner's Name and Address (if different than insured)
Optional
Driver's Name and Address (if not owner and insured)
Optional
Driver's License Number
Optional
Describe Damage
Required
Estimate Amount
Optional
When can vehicle be seen?
Required
Other insurance on vehicle
Optional
Other Vehicle Damaged
Year
Required
Make
Required
Model
Required
VIN
Optional
Plate Number
Optional
Describe Property (Other than Vehicle)
Required
Carrier
Optional
Policy Number
Optional
Owner's Name and Address
Required
Primary Phone Number
Required
Driver's Name and Address (If not owner)
Optional
Primary E-Mail Address
Required
Describe Damage
Required
Estimate Amount
Optional
Where can damage be seen?
Required
Injured Information
Name and Address
Optional
Primary Phone Number
Optional
Type
Optional
Age
Optional
Extent of Injury
Optional
Witnesses or Passengers
Name and Address
Optional
Primary Phone Number
Optional
Type
Optional
Other (Specify)
Optional
Submission Validation
Required
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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.

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Please note that we cannot bind insurance via email, fax, or phone. Any quotes given are subject to underwriting guidelines by the respective insurance carriers. Any reference of coverage used are not intended to express legal opinion as to the nature of coverage, but rather just a brief generalization of coverages. Please read your policy for specific details of coverages.
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ECI Agency, Inc. | 325 Piedmont Rd N | Piedmont, OK 73078 | Ph: (405) 373-2977  M-F 8am-5pm Powered by Insurance Website Builder