(208) 322-3473 stan@hartleyonline.com

Other Claim Submission

Please answer as many questions as you can with the most accurate information available to you.
If you are not contacted within 2 business days after submitting this claim please contact Hartley Insurance or your insurance company directly by phone.



PERSONAL
INFORMATION
Your
name:
First:

Last:

E-Mail
address:


Phone
numbers:
Daytime:

Evening:

Fax:

How
would you prefer to be contacted?


Phone

Fax

Mail

E-mail
If
you would prefer to be contacted by phone,
please let us know the best time to call.


Address:

City:

State:

Zip
code:



Best time to contact
you:


Time
and Date of claim:


 


NON-AUTOMOBILE
INSURANCE CLAIM
Location
of Accident


Insured
Vehicle :
Owner:

Driver:

Other
Vehicle :
Owner:

Driver:

How
would you prefer to be contacted
regarding your change?


Phone

Fax

Mail

E-mail
Other
party’s Name


Other
party’s Address:


City:

State:

Zip
code:


Were
police notified:


yes

no
Report
number:


Who
was cited?
Name
of any witness:
Was
anyone injured?

yes

no
What
happened?

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