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| REPORT AN AUTO CLAIM |
| WESTERN NATIONAL INSURANCE GROUP |
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| * Denotes required fields.
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| Western National Policyholder Information |
| Type of Policy
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| Policy Number * |
| WN Policyholder's Name
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| Address |
| City |
State
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Zip |
| Contact Name * |
Contact Phone * |
| Driver's Name * |
| Vehicle Description (Year, Make, Model) * |
| Person Submitting Claim is:
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| E-mail of Person Submitting Claim:
*
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| Other Party Information |
| Name of Other Party |
| Address |
| City |
State
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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. |
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| Loss Information |
| Date of Loss * |
| Loss Location |
| Location of Damaged Property * |
| Description of Accident or Loss * |
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| Other Vehicles & Property Damage Information |
| Were there any other vehicles damaged?
No
Yes
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| If yes, how many?
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| If yes, please provide details. |
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| Was there damage to property other than vehicles?
No
Yes
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| If yes, please provide details. |
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| Injury Information |
| Was anyone injured?
No
Yes
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If yes, how many?
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| Name of Injured Party(s) | Description of Injury | Telephone Number |
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| If more than 4 injuries, please list below |
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