Find Agents

Claim Department
Contacts

Lynn Rupp

Senior Vice President – Claims
201-847-2848


Lisa Rosa

Vice President – Claims
201-847-2847


Gerald Steimers

Second Vice President – Claims
201-847-2899


Rosa Avella

Claims Administrative Assistant
201-847-2863


Required Fields *

Date of Accident *
Format XX/XX/XXXX
Time of Accident
Previously Reported?

CONTACT

Name *
Email
Address *
Business Phone *
Residence Phone *
Where to contact
When to contact

INSURED

Name *
Address *
Business Phone *
Residence Phone *
Where to contact
When to contact

COVERAGE

Policy Number *
Effective Dates of Coverage
From To
Agent's Name *
Agent's Address *
Agent's Phone *

LOCATION OF ACCIDENT - (Include City and State)

Authority Contacted
Violations/Citations
Location
Report Number
Description of Accident *

INSURED VEHICLE

Body Type
VIN *
Plate No.
State
Driver's Name and Address *
Business Phone
Residence Phone
Description of Damage *
Vehicle No.
Year *
Make *
Model *
Owner's Name and Address
Business Phone
Residence Phone
Relation to Insured
Birth Date
Driver License No. *
Purpose of Use
State *
Used with Permission?
Estimate $ Amount$
Other insurance
on vehicle?
Where can vehicle
be seen?
When can vehicle
be seen?

PROPERTY DAMAGE

AUTO (if applicable)
Year
Make
Model
Plate No.
Describe Property *
Other vehicle/property insurance?
Company/Agency Name
Policy No.
Other Driver's Name and Address
Business Phone
Residence Phone
Description of Damage *
Owner's Name and Address *
Business Phone *
Residence Phone *
Estimate $ Amount *
$
Other insurance
on property?
Where can damage
be seen?
When can damage
be seen?

FIRST INJURED PARTY

Age
Sex
Select one:
Name (Injured) *
Phone No. *
Include Area Code
Address (Injured) *
Extent of Injury *

SECOND INJURED PARTY

Age
Sex
Select one:
Name (Injured)
Phone No.
Include Area Code
Address (Injured)
Extent of Injury

WITNESSES OR PASSENGERS

First
Select one:
Name
Phone No.
Address
Second
Select one:
Name
Phone No.
Address

FRAUD WARNING: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the porpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
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