Empower Insurance - File a Claim

Form Progress

Basic Info
Insured
Claimant
Facts
Injuries
Witnesses

Basic Information

Your Name:

Your Phone Number:

Loss Date:

Loss Time:

Empower Policy Number:

Insured

Empower Policy Holder

First Name:

Middle Initial:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Driver

First Name:

Last Name:

Date of Birth:

Driver License Number:

Relationship to Named Insured:

Street Address

City:

State:

Zip:

Home Phone:

Other Phone:

Driver's Insurance Company:

Injured?:

Description of Injury:

Where Taken?:

Doctor's Name:

Number of Passengers:

Permission to Use Vehicle?:

Seat Belt Worn?:

Air Bag Activated?:

Ambulance to Hospital?:

Insured's Vehicle Description

Year:

Make:

Model:

Color:

License Plate Number:

License Plate State:

VIN Number:

Point of Impact:

Vehicle Drivable?:

Vehicle Towed?:

List all damaged areas of vehicle due to this incident:

Estimated Repair Cost:

Insured's Vehicle Current Location

Name of Establishment:

Street Address:

City:

State:

Zip:

Phone:

Contact Person:

« Previous

Claimant

Claimant - Not an Empower Policy Holder

First Name:

Middle Initial:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Driver

First Name:

Last Name:

Date of Birth:

Driver License Number:

Relationship to Named claimant:

Street Address

City:

State:

Zip:

Home Phone:

Other Phone:

Driver's Insurance Company:

Injured?:

Description of Injury:

Where Taken?:

Doctor's Name:

Number of Passengers:

Permission to Use Vehicle?:

Seat Belt Worn?:

Air Bag Activated?:

Ambulance to Hospital?:

Claimant's Vehicle Description

Year:

Make:

Model:

Color:

License Plate Number:

License Plate State:

VIN Number:

Point of Impact:

Vehicle Drivable?:

Vehicle Towed?:

List all damaged areas of vehicle due to this incident:

Estimated Repair Cost:

Claimant's Vehicle Current Location

Name of Establishment:

Street Address:

City:

State:

Zip:

Phone:

Contact Person:

« Previous

Facts

Location of Loss

Address / Intersection:

City:

State:

Description of Accident:

Road Conditions:

Speed Limit: miles per hour

Police Report?:

Location & Precinct:

Case Number:

Tickets Issued?:

Issued Against:

Type of Tickets:

« Previous

Injuries

Number of People Injured:

Injured Person #1

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

Date of Birth (or Age):

Description of Injury:

This injured person was...

Taken in Ambulance?:

Treatment Location:

Doctor's Name:

Injured Person #2

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

Date of Birth (or Age):

Description of Injury:

This injured person was...

Taken in Ambulance?:

Treatment Location:

Doctor's Name:

Injured Person #3

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

Date of Birth (or Age):

Description of Injury:

This injured person was...

Taken in Ambulance?:

Treatment Location:

Doctor's Name:

Note: Information on any additional injured persons will be taken when we contact you.

« Previous

Witnesses

Witness Number 1

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Other Phone:

Witness Number 2

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Other Phone:

« Previous

File a Claim

Form Progress

Empower Policy Holder

Driver

Insured's Vehicle Description

Insured's Vehicle Current Location

Claimant - Not an Empower Policy Holder

Driver

Claimant's Vehicle Description

Claimant's Vehicle Current Location

Location of Loss

Injured Person #1

Injured Person #2

Injured Person #3

Witness Number 1

Witness Number 2

Empowerins.com

Agent Area

Customer Area

Contact Us