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Mangold Insurance Auto Claim Form
We are sorry to hear about your loss. As claim service is one of our most important responsibilities, we will strive to have your claim processed promptly and fairly.

Personal Information

 Name:


 Address:


 City:


 State:


 Zip:


 Phone:


 Cell:


 Email:


Insured Driver and your Vehicle Information

 Drivers Name:


 Insurance Company:


 Policy Number:


 Date of Accident:


 Time of Accident:


Accident Location:
 Address:


 City:


 State:


 Zip:


 Vehicle Year:


 Make:


 Model:


 Describe Damage to Vehicle:


 Is Vehicle Driveable?   

 Explain Circumstances of Accident:


Other Driver and Vehicle Information

 Name:


 Phone:


 Address:


 City:


 State:


 Zip:


 Insurance Company:


 Policy Number:


 Vehicle Year:


 Make:


 Model:


 Describe Damage to Vehicle:


Injuries, Authorities and Witnesses

 Any Injured Drivers or Passengers?   

 If Yes, please explain:


 Authority on the Scene:


 Any Tickets Issued?   

 If Yes, please explain:


 Any Witnesses?   

 If Yes, please list:




 If you would like to share any additional information:


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Please Note: The information contained in this Web Site is provided solely as a source of general information and resource. It is not a statement of contract and coverage may not apply in all areas or circumstances. For a complete description of coverage's, always read the insurance policy, including endorsements. Hyperlinks are provided as a service only. Mangold Insurance, Inc., is not responsible for their content. All rights reserved.
Mangold Insurance, Inc.   |   262.763.7644 or 800.242.2282   |   Email Us