Walock-Johnson Insurance, Inc. | Report an Auto Claim

Report an Automobile Insurance Claim

Please note that submitting a claim from this website does not confirm coverage or authorize payment. An agency representative will verify your coverage and contact you to complete the claims process.

Important: If this claim involves more than two people, please contact our agency directly to report it.

Policy Number

(if you know it)

Full Name

Contact Information

Who should the claims adjuster contact regarding repairs?

Name

Email Address

REQUIRED

Home Telephone

Work Telephone

Authority Contacted

Police Department

Police Report Number

Claim Information

Date of Accident

Location of Accident

Cause of Accident

Describe, if other cause of loss

Injuries

Reminder: If more than two people are involved, please contact our agency directly to report the claim.

Information about person injured

Name

Address

Telephone Number

Nature of injuries

Information about person injured

Name

Address

Telephone Number

Nature of injuries

Damage to Your Vehicle

Year, Make & Model

Driver Name

Driver Address

Driver Telephone Number

Describe the damage to your vehicle

Location of vehicle now

Damage to Other Vehicle

Year, Make & Model

Owner's Name

Owner's Address

Owner's Telephone Number

Driver Name

Driver Address

Driver Telephone Number

Describe the damage to the vehicle

Insurance agent and/or company

Accident Details

Describe what happened

Comments and/or other information

Rutland 701-724-6484		Lisbon 701-683-5253		Milnor 701-427-5215		Gwinner 701-678-2771