Personal Lines Automobile Claim Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Alternate Phone Number

E-Mail Address *

Policy Number *

Incident Overview

Date and Time of Accident *

What vehicle was involved? *

How severe was the damage? *

Is the vehicle drivable? *

Descripton of Insured Vehicle Damages

Where is the vehicle currently located? *

What is the phone number for the location?

Incident Location

Street *

City *

State *

Incident Description

Describe the incident. *

Other Vehicle Information

Was another vehicle involved? *

Year, Make and Model of other vehicle involved.

Description of Damages to Other Vehicle

Owner of Other Vehicle Involved

Street *

State

Phone Number

Name of Driver (First, Last)

Street *

State

Phne Number

Injuries

Any Injuries? *

Name (First, Last)

Phone Number

Description of Injuries

Name (First, Last)

Phone Number

Description of Injuries

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Valley Agency Company
(717) 264-4311
797 Fifth Avenue - Chambersburg, PA 17201