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Fill out this Form and
we will contact you as
soon as possible to
discuss your claim.
We're very sorry to hear you were in an
accident. You can submit your vehicle claim
using this form. If you have any questions,
please call our claim department at
1-800-854-6011.

Note: You must have a Camelot Insurance
Auto and/or Home policy to use this form.
To better serve you please fill out all of the fields that apply
* Required Field
Your name:
*
Email:
*
Address:
City:
State:
Zip Code:
*
Telephone:
Policy Number
Driver's License #
Optional
License State:
Date of accident:
Police Case Number:
Were you or anyone else injured and/or received
medical treatment as a result of this accident?
No Injuries
Injuries
We’re very sorry to hear that someone was injured in
your accident! Accidents involving injuries require
specialized claims support. One of our associates
will be contacting you as soon as possible to discuss
the details.
Policy Holder Vehicle
Vehicle Year:
Make:
Model:
Vehicle Color
Licence Plate
Accident Informatioin
Please give us location of the damage.
Front Bumper
Roof
Hood
Left Fender
Right Fender
Right Doors
Left Doors
Left
Quarter Panel
Right
Quarter Panel
Rear Trunk
Rear Bumper
Other Driver(s) Information
Name:
mm / dd / yyyy
Birth Date
Telephone:
Vehicle Year
Make:
Model:
License Plate #
License Plate State
Did other driver have insurance?
Yes
No
If Yes, Company Name
Policy number
Finally, please provide an explanation of the accident including but not
limited to name(s) of streets, direction vehicles were traveling, weather
conditions, speed limits, along with any other information you would like to
share. Please include the name(s) and contact information for any other
drivers or witnesses whose information you collected but haven't already
provided.
Comments