OUR OFFICE
PO Box 261240, Plano, TX 75026
EMAIL US
service@ad-ga.com
CALL US
+1 888 509 2342
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Complete the form below to report your insurance claim
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Insured Information
First Name
*
Last Name
*
Email
*
Residence Phone
Business Phone
Cell Phone
Street Address
City
State
ZIP Code
Policy Information
Policy Number
*
Loss Information
Date of Loss
*
Time of Loss
*
Location of Accident
*
Description of Accident
*
Authority Contacted
Report Number
Violations/Citations
Driver & Vehicle Information
Driver's Name
Driver's License Number
Driver's Address
Driver's Phone Number
Driver's Relationship to Insured
Purpose of Use
Vehicle Used with Permission?
Yes
No
Vehicle Details
Year
Make
Model
VIN
Damage Description
Estimate Amount
Vehicle Location
Vehicle Viewing Time
Other Insurance
Property Damage
Another Vehicle Damaged?
Yes
No
Non-vehicle Property Damaged
Property Owner Name
Property Owner Phone
Property Owner Address
Property Damage Description
Property Insured?
Yes
No
Injured Persons
Person 1
Location When Injured
Select location
Pedestrian
Insured Vehicle
Other Vehicle
Name
Age
Address
Phone
Extent of Injury
Add Injured Person
Witnesses
Witness 1
Location
Select location
Pedestrian
Insured Vehicle
Other Vehicle
Name
Age
Address
Phone
Add Witness
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