Name: DSD Insurance an Acrisure Agency Partner
Address: 135 Hayesbury Drive, Pelham, AL, 35124, US
Telephone: (205) 621-1770

Commercial Auto Claim Form
Please fill out the customer contact and/or corporate company information below.
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Name
First Last
Incorporated Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Mobile Phone Number
Alternate Phone Number
E-mail Address
Policy Number
Insured Vehicle Driver Information
Insured Vehicle Driver (IVD) Name
First Last
IVD Mobile Phone Number
IVD Driver's License Number
IVD Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Incident Overview
What date did the incident take place?
MM slash DD slash YYYY
What time of day did the incident occur?

: Hours

Minutes

AM/PM
What customer vehicle was involved?
What is the Customer Vehicle Identification Number (VIN)?
How severe was the damage?
Is the vehicle driveable?
What is the name of the business where the vehicle is currently located?
What is the phone number for the vehicle location?
Was another vehicle involved?
How many other vehicles?
Other Party Information
What are the names and phone numbers of other involved individuals?
Incident Location
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Incident Description
Please describe the incident:
What law enforcement agency responded to this incident, if any?
What is the police report or case number?
Upload Claim Documents
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Max. file size: 59 MB.
Comments
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Commercial Auto Claim Form

Insured Vehicle Driver Information

Incident Overview

Other Party Information

Incident Location

Incident Description