Claims

First Name *

Last Name *

Street Address

Address Line 2

City *

State

Zip Code *

Email *

Cell (Day) *

Cell (Evening)

Date incident occurred *

Date incident reported *

Time incident occurred *

Street Name, Hwy Name, and City

Which lane and direction of travel

Distance in relation to nearest intersection

List or describe property damaged (house, yard, or other property)

Year

Make

Model

VIN Number

Tag Number

What caused the damage: (something in the roadway, a piece of equipment, or the construction in general)*

Accepted file types: jpg, tiff, png, pdf, gif, Max. file size: 50 MB.

Was a police report written? * YesNo

Did you Contact any E.R. Snell Employee at the site of incident? * YesNo

Description of how incident occurred *