File a Claim | Hillco General Agency

FILE A CLAIM

To file a claim, please complete and submit this form and a Hillco General Agency agent will be in touch with you soon.

Step 1 - Personal Information

First Name

Last Name

Email Address

Mobile Phone

Home Phone

Home Address

Your Vehicle Details

Are you insured by Hillco?

If, YES, what is your Hillco policy number?

Hillco Policy Number

If, NO, what is the name of the insured person?

Hillco Insured Name

Step 2 - Accident Information

Date of Accident or Loss

Time of Accident or Loss

Location of Accident

Description of Accident

Did any injuries occur as a result of the accident?

If, YES, tell us more about the injuries.

Description of Injuries

Damaged Area(s) on Vehicle

Do you have any photos of the accident?

If, YES, please upload them below.

Upload Photo

Where is your vehicle currently located?

We're the police notified?

If, YES, please share police information.

Police Department

Police Report Number

Step 3 - Hillco Insurance Information

Hillco Policy Number

Hillco Named Insured

Insured Vehicle Details

Name of Insured Vehicle Driver

Phone Number of Insured Vehicle Driver

Name(s) of Insured Vehicle Passengers

Step 4 - Claimant Information

Claimant First Name

Claimant Last Name

Claimant Email Address

Claimant Phone

Claimant Address

Claimant Vehicle Details

Name of Claimant Vehicle Driver

Phone Number of Claimant Vehicle Driver

Name(s) of Claimant Vehicle Passengers

Claimant Insurance Company

Claimant Insurance Policy Number

Step 5 - Witness Information

Witness #1 - First Name

Witness #1 - Last Name

Witness #1 - Email Address

Witness #1 - Phone Number

Witness #2 - First Name

Witness #2 - Last Name

Witness #2 - Email Address

Witness #2 - Phone Number

Witness #3 - First Name

Witness #3 - Last Name

Witness #3 - Email Address

Witness #3 - Phone Number

Thanks for submitting our claim form. An agent will be in touch with you soon.