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If reporting for homeowners insurance or commercial lines please call 773-458-1055.

Step 1 of 14

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Are you an insured or representing an insured with Stonegate Insurance?*
- Yes
- No
*
- I was the person involved in an accident
- I am an attorney representing an insured
- I am an agent representing an insured
*
- I am a person who was involved in an accident with a Stonegate insured
- I am an attorney representing a person who was involved in an accident with a Stonegate insured
- I am an agent representing a person who was involved in an accident with a Stonegate Insured
Reporter's Name*
First Middle Last
Reporter's Phone*
Reporter's Email*

General Information
Stonegate Insurance Policy Number*
Date of Accident*
Date Format: MM slash DD slash YYYY
Time of Accident*

: HH

MM
Location of Loss
Street Address City
*
State

Stonegate's Insured Vehicle Information
Vehicle Year
Vehicle Make
Vehicle Model
License Plate Number
Vehicle Color
Vehicle Identification Number - VIN
Choose the option that most applies*
Is there damage to this vehicle?*
Vehicle Damage
Initial Point of Impact
Please use the above image to assist with this answer.
Unrelated Prior Damage
Is the Vehicle Drivable?
- Yes
- Unknown
- No
Where is the vehicle Located?
Street Address Address Line 2 City State ZIP Code
Is this address a business?
- Yes
- No
Business Name
Business Phone Number

Stonegate Policyholder Information
Registered Owner Information
Name*
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email

Stonegate Driver Information
Same as Vehicle Owner?*
- Yes
- No
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Drivers License Number
Drivers License State
State
Did this person receive a ticket?
- Yes
- Unknown
- No
Ticket Reason
Was this person injured?
- Yes
- No
Describe Injuries:
Did they seek medical treatment?
- Yes
- No
Purpose of Use

Stonegate's Vehicle Passenger Information
How Many Passengers in Stonegate's vehicle(other than the driver)?
Passenger 1
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Was this person injured?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 2
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Was this person injured?
- Yes
- No
Describe the Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 3
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Was this person injured?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 4
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Was this person injured?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown

Other Vehicle Information
Is there another Vehicle Involved?
- Yes
- No
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Identification Number - VIN
Plate Number
Vehicle Color
Is there damage to this vehicle?*
Vehicle Damage
Initial Point of Impact
Unrelated Prior Damage
Is the Vehicle Drivable?
- Yes
- Unknown
- No
Where is the Vehicle Located?
Street Address Address Line 2 City State ZIP Code
Is this address a business?
- Yes
- No
Business Name
Business Phone
Insurance Company Name
Insurance Company Policy Number

Other Vehicle Owner Information
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Work Phone
Home Phone
Email

Other Vehicle Driver Information
Is the Driver the Same as the Vehicle Owner?
- Yes
- No
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email
Driver's Date of Birth
Date Format: MM slash DD slash YYYY
Driver's License Number
Driver's License State
State
Were there any injuries to the driver?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
Were any tickets issued to this driver?
- Yes
- No
Ticket Reason

Other Vehicle Passenger Information
How many Passengers in the other Vehicle?(other than the driver?)
Passenger 1
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Were there any Injuries?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 2
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Were there any injuries?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 3
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Were there any injuries?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown
Passenger 4
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Were there any injuries?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown

Was a pedestrian involved in this accident?
- Yes
- No
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Cell Number
Work Phone Number
Home Phone Number
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Was this person injured?
- Yes
- No
Describe Injuries:
Did this person seek medical treatment?
- Yes
- No
- Unknown

Fixed Object Information
Was a fixed object involved?
- Yes
- No
Describe Fixed Object
Describe Damage to Fixed Object
Fixed Object Owner
First Last
Fixed Object Address
Street Address Address Line 2 City State ZIP Code
Fixed Object Owner's Email
Fixed Object Owner's Phone

Accident Details
Describe what happened in the accident:*
Were the police notified?*
- Yes
- No
Police Department
Police Report Number
Reported through
Any additional Comments?

Disclaimers
If applicable, we may want to send you an email or text message with a link which provides instruction to take photographs of your damaged vehicle.
Do you give your permission?*
- No
- Yes, send me a text message
- Yes, send me an email
*
We will send a text message to this provided phone number.
*

We will send an email to this provided email address.
Law requires vehicle owners to mitigate their damages, whether the vehicle is disabled or not. This includes, but is not limited to, protecting the vehicle from further damage and to move the vehicle to a storage free location.
If your vehicle, whether disabled or not, is at any facility incurring charges for any reason, please be advised that you have the duty to move your vehicle to a storage free location.
We will not be responsible for, nor will we pay, any unreasonable towing or storage fees incurred, prior to, during or after our involvement due to your failure to mitigate your loss.
Do you understand and accept these conditions?*
Yes

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