American Millennium Insurance Company (AMIC)

ACCIDENT INFORMATION

Accident Date(required)

Accident Time

Accident Location

Address

City(required)

State(required)

Zip Code

Accident Description(required)

Were Police Called?

Yes

No

If yes, Police Department Name

Report Number

Were any tickets issued by the Police, if so, please describe

POLICYHOLDER INFORMATION

AMIC Policyholder Name

Policy Number(required)

Policyholder Street

City

State

Zip Code

Contact Name

Last

First

Phone Number

POLICYHOLDER VEHICLE INFORMATION

Year

Make

Model

VIN

License Plate No.

If applicable, was policyholder vehicle damaged?

Yes

No

If yes to above, area of damage

Photos Taken

Yes

No

If yes to above, click below to upload images

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Maximum size 10MB

Name of Driver

Last

First

Middle

Driver Date of Birth

Driver Gender

Male

Female

Driver Social Security Number

Driver Phone Number

Driver License Number

Number of Passengers

Name of Passengers and Contact Information, if available

Separate names using a comma

OTHER VEHICLE INFORMATION

Year

Make

Model

VIN

License Plate No.

If applicable, was other vehicle damaged?

Yes

No

Area of Damage

Photos Taken

Yes

No

If yes to above, click below to upload images

Browse...

Maximum size 10MB

Name of Vehicle Owner

Last

First

Middle

Owner Date of Birth

Owner Gender

Male

Female

Owner Social Security Number

Owner Phone Number

Vehicle Owner Insurance Company

Policy Number

Street Address or PO Box

City

State

Zip Code

DRIVER INFORMATION

Name of Vehicle Driver

Last

First

Middle

Driver Date of Birth

Driver Gender

Male

Female

Driver Social Security Number

Street Address or PO Box

City

State

Zip Code

Drivers Phone Number

Drivers License Number

Number of Passengers

Name of Passengers and Contact Information, if available

Separate names using a comma

Vehicle Driver Insurance Company

Policy Number

WITNESS INFORMATION

Were there any witnesses present?

Yes

No

If yes, please provide name(s), address(es) and phone number(s)

OTHER INFORMATION

If something other than the vehicle was damaged, please describe other important claim information or comments

Name of person completing report(required)

Your relationship to claim

Email address(required)

Phone Number(required)

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