Name

Spouse

Address                                                                      City                                               State          Zip

Phone (H)                                            Phone (W)                                         Phone (Cell)

E-mail

Claim Information:

Date of Accident/Loss:   (e.g. 02/23/2007)

Location of Accident/Loss:  

Description of Accident/Loss & Damage:

Estimate Amount: $

Where can damage be seen?

Anyone injured?   Yes   No

Authorities or Fire Department Contacted? Yes No

Name of Department 

Name of Officer 

Other Parties/Property Involved in Accident/Loss:

(Please include each additional individual's name, address, and phone number:)

Other Party Vehicle:

Year:  Make:  Vehicle:

Other Party Insurance Company: Policy#:

Witnesses:

Please include each individual's name, address, and phone number:

AUTO CLAIM:

Violations/Citations?

Vehicle that was damaged: Year   Make   Model

Drivers Name:

Relation to Insured:

PROPERTY CLAIM:

Item that was damaged:

MPCI CROP/CROP HAIL CLAIM:

Time of Loss:

Crop: Wheat Corn Barley Oats Flax Other

Type of Loss: Hail Drought Wind Insects Other

Preventive Planting (must be reported within 72 hrs of final planting date)

Remarks:

If accident results in serious bodily injury or extensive property damage please call 1-800-435-0310 or (701)-475-2340.