MiddleOak

Agent Services

Customer Care

Please Select a State Below

Report an Auto Claim

Customer Care

Customer Care Home

Claims Reporting

Contact Information

Last Name *

First Name *

Phone Day *

Phone Evening *

Email Address *

If you would like to receive a return e-mail with your claim number, please provide your e-mail address.

Policy Holder Information

Policy Number

Policy Holder - Name

Policy Holder - Phone

Policy Holder - Address

Policy Holder - City

Policy Holder - State

Zip Code

Accident Information

Date of Accident

/ /

Time of Accident

AM PM

Check this if Accident Location matches Policy Holder Address

Accident Location - Address

Accident Location - City

Accident Location - State

Zip Code

Brief Description of the Accident:

Police/Fire Contacted

Yes

Police/Fire Report Number

Police/Fire Department Name

Any Witness Present

Yes

Did injuries result from Accident

Yes

If Yes to above, please provide:
Name, Address, Phone Number, and Extent of Injuries of those Injured.

Damage Information

Was Policy Holder Vehicle Damaged

Yes

If Yes to above, please provide the following:

Vehicle Year

Vehicle Make

Vehicle Model

Brief Description of Damage

Where can the Vehicle be seen

If other Vehicles Damaged please Describe

Please Describe Additional Property Damage

A Claim Representative will contact you.

Policies issued by Holyoke Mutual Insurance Company in Salem - Salem, MA and Middlesex Mutual Assurance Company - Middletown, CT
© 2006-2008 Middlesex Mutual Assurance Company. Click here for our privacy policy, and our terms and conditions.