Online Automobile Claim Form (WNA)


REPORT AN AUTO CLAIM
WESTERN NATIONAL INSURANCE GROUP
* Denotes required fields.
Western National Policyholder Information
Type of Policy
Policy Number *
WN Policyholder's Name
Address
City	State	Zip
Contact Name *	Contact Phone *
Driver's Name *
Vehicle Description (Year, Make, Model) *
Person Submitting Claim is:
E-mail of Person Submitting Claim: *
Other Party Information
Name of Other Party
Address
City	State	Zip
Contact	Contact Phone
Driver's Name
Vehicle Description (Year, Make, Model)
Additional Other Parties and/or Witnesses
If additional other party information, please enter in the text box below.

Loss Information
Date of Loss *
Loss Location
Location of Damaged Property *
Description of Accident or Loss *

Other Vehicles & Property Damage Information
Were there any other vehicles damaged? No Yes
If yes, how many?
If yes, please provide details.

Was there damage to property other than vehicles? No Yes
If yes, please provide details.

Injury Information
Was anyone injured? No Yes	If yes, how many?
Name of Injured Party(s)	Description of Injury	Telephone Number




If more than 4 injuries, please list below