Commercial Auto 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.

Business Information

Business Name *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Alternate Phone Number

E-Mail Address *

Accident Location

Street *

City *

State *

ZIP / Postal Code *

Driver Information

First Name *

Last Name *

Street Address *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Accident Overview

Date and Time of Accident *

What vehicle was involved? *

Describe the incident. *

How severe was the damage? *

Descripton of Insured Vehicle Damages

Is the vehicle drivable? *

Where is the vehicle currently located? *

What is the phone number for the location?

Other Vehicle Information

Was another vehicle involved? *

Owner of Other Vehicle Involved

Address

Phone Number

Driver of other vehicle

Address

Phone Number

Year, Make and Model of other vehicle involved.

Description of Damages to Other Vehicle

Injuries

Any Injuries? *

Describe Injuries (if any) *

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