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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
Required
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Accident Location
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Driver Information
First Name
Required
Last Name
Required
Street Address
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Accident Overview
Date and Time of Accident
Required
What vehicle was involved?
Required
Describe the incident.
Required
How severe was the damage?
Required
Descripton of Insured Vehicle Damages
Optional
Is the vehicle drivable?
Required
Where is the vehicle currently located?
Required
What is the phone number for the location?
Optional
Other Vehicle Information
Was another vehicle involved?
Required
Owner of Other Vehicle Involved
Optional
Address
Optional
Phone Number
Optional
Driver of other vehicle
Optional
Address
Optional
Phone Number
Optional
Year, Make and Model of other vehicle involved.
Optional
Description of Damages to Other Vehicle
Optional
Injuries
Any Injuries?
Required
Describe Injuries (if any)
Required
Submission Validation
Required
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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.

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