File an Insurance Claim with Amistad Insurance

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Enter First and Last name of the Amistad Insurance Policy Holder:*

Enter policy number and name of the insurance company:

Date of Loss:*

Time of Loss:*

Brief Description of What Happened:*

Was anyone injured in this loss:

If anyone was injured, please list the name or names below:

Did an ambulance go to the scene of the accident?:

Was anyone transported to the hospital?:

If yes, please write down the name of the person or persons who were transported.

What vehicle was involved in the loss:

What side of the vehicle was damaged (Front, Rear, Driver's side Front, Driver's side rear, Passenger's side Front, Passengers side rear):

Name of the person reporting the loss:

Name of the person driving, at the time of the loss:

Was there a police report:

Street and City where the accident occurred:

Named insured address:

List all contact telephone numbers:

Select ALL That Apply

My vehicle was damaged or stolen.

Someone else's vehicle was damaged.

Someone in my vehicle was injured.

Someone in another vehicle was injured.

A pedestrian was injured.

Insured Email*

OPTIONAL: Comments/Uploads (Photos, Police Report, etc.)