Cooper Insurance Group

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

Auto Insurance
Report a Claim
If more than 2 people are involved,
please call our agency directly to report the claim.
Policy Number:
Your Name:
Contact Person:
Whom should the adjuster contact about repairs?
Home phone:
Work phone:
Email address:
Authority Contacted:
Police department:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Describe, if other cause of loss:
Your Damaged Car:
Driver's name/address:
Driver's phone number:
Describe your damage:
Is the car driveable? Yes      No
If not, where is it located?
Persons Injured:
Name and address:
Phone number:
Nature of Injuries:
Describe Other Car:
Owner's name/address:
Owner's PH#
Driver's name/address:
Driver's phone number:
Describe damage:
Insurance agent/company:
Describe What Occurred:
Comments and/or Other Information

Please Note: Insurance coverage cannot be bound without a written binder from our office.

Print Form