Online Auto Accident Report Form - Brown & Brown Garden City

Step 1 of 2

Please use this form to submit an Auto Accident Report. For immediate assistance please call us at 516-745-0000 or Toll Free at 800-221-2834
Insured (Primary Policy Holder) Contact Information
Company Name (if applicable)
Your Name
First Last
Insured Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured Phone
Insured Email
Insured Vehicle Owner Information
Insured Vehicle Owner Name
First Last
Insured Vehicle Owner Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured Vehicle Owner Phone
Insured Vehicle Owner Email
Insured Vehicle Description, Registration & Damage Information
Insured Vehicle Make
Insured Vehicle Model
Insured Vehicle License Plate
Insured Vehicle Registered State
Insured Vehicle Damage
Insured Vehicle Driver Information
Vehicle 1 Driver Name
First Last
Vehicle 1 Driver Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vehicle 1 Driver Phone
Vehicle 1 Driver Email
Loss Date, Time, Location & Report Number(s)
Date of loss
Month
Day
Year
Time of Loss

: Hours

Minutes

AM/PM
Location of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Police Precinct or Fire Dept. Report Number
Description of Accident
Vehicle 1 is your car. Vehicle 2 (3) are other(s).

How many other vehicles were involved in the accident?
Vehicle 2 Owner Information
Vehicle 2 Owner Name
First Last
Vehicle 2 Owner Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vehicle 2 Owner Phone
Vehicle 2 Owner Email
Vehicle 2 Driver Information
Vehicle 2 Driver Name
First Last
Vehicle 2 Driver Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vehicle 2 Driver Phone
Vehicle 2 Driver Email
Vehicle 2 Description, Registration & Damage Information
Vehicle 2 Make
Vehicle 2 Model
Vehicle 2 License Plate
Vehicle 2 Registered State
Vehicle 2 Insurance Company
Vehicle 2 Insurance Policy #
Vehicle 2 Damage
Vehicle 3 Owner Information
Vehicle 3 Owner Name
First Last
Vehicle 3 Owner Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vehicle 3 Owner Phone
Vehicle 3 Owner Email
Vehicle 3 Driver Information
Vehicle 3 Driver Name
First Last
Vehicle 3 Driver Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vehicle 3 Driver Phone
Vehicle 3 Driver Email
Vehicle 3 Description, Registration & Damage Information
Vehicle 3 Make
Vehicle 3 Model
Vehicle 3 License Plate
Vehicle 3 Registered State
Vehicle 3 Insurance Company
Vehicle 3 Insurance Policy #
Vehicle 3 Damage
Injured Party Information - Name, Address, Phone, Email
Witness Information - Name, Address, Phone, Email
PLEASE NOTE: No claim can be considered reported until you receive written confirmation from this office or the insurer.

Step 1 of 2

Insured (Primary Policy Holder) Contact Information

Insured Vehicle Owner Information

Insured Vehicle Description, Registration & Damage Information

Insured Vehicle Driver Information

Loss Date, Time, Location & Report Number(s)

Vehicle 2 Owner Information

Vehicle 2 Driver Information

Vehicle 2 Description, Registration & Damage Information

Vehicle 3 Owner Information

Vehicle 3 Driver Information

Vehicle 3 Description, Registration & Damage Information