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What Happens Next
Start My Claim
About Us
Contact

Florida Accident Assist - Intake Form

We’ll help you report your claim, get your crash report, and obtain your claim number. Complete this short form so we can assist you right away!

Personal Information:

*First name

*Last name

*Phone number

Email

Preferred Contact Method:

Phone

Text

Email

Accident Details:

Date of Accident:

Time of Accident:

Time

:HoursMinutes

Location of Accident

Were There Any Injuries?

Yes

No

If Yes, Please Describe:

Was A Police Report Made?

Yes

No

If Yes, Report Number:

Vehicle Information:

Vehicle Make/Model/Year:

Was Your Vehicle Towed?

Yes

No

If Yes, Where Is Your Vehicle Now?

Insurance Information:

Name Of Your Insurance Company?

Policy Number:

Do You Already Have A Claim Number?

Yes

No

If Yes, Claim Number:

Other Party (if applicable)

Other Driver's Name:

Their Insurance Company:

How Can We Help You Today?

Multi choice

File or report my claim

Obtain a crash report

Get a claim number

Other (please describe)

Authorization

I authorize Florida Accident Assist to help me contact my insurance company and obtain my crash or claim information.

Signature

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Date

Month

Day

Year

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Email

Phone

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