Charles, Garland and Harris Agency
Online Claim Form 

Please fill out the following:

Type of claim - Choose one
Auto
Property
Other - Name type

Enter the Date of the Incident

Month
Day
Year
Enter the Time of the Incident
Am  Pm		 If you are insured with us,
Enter Your Policy Number

Enter your Name (* Required)

Enter your E-mail Address (* Required)

Your Daytime Number

Your Evening Phone Number

Your Street Address:

City

State

Zip
Describe what happened and any damage done.
Have the Police been notified?
Yes No
Has there been a Police Report?
Yes No
Was anyone injured?
Yes
No
Unknown
If yes, Please give their name, address, & phone number.
Please give the name of the medical facility they were transferred to.
NOTE - If this is for an Auto Accident Fill out the following questions for both drivers.
DRIVER #1 (Insured) Given Citation? Yes  No
  Type of Vehicle
Year
Make
Model
Drivers Name, Address, Phone number.
Enter "Same" if information matches above.

DRIVER #2  (Other)
Given Citation?Yes No
 

Type of Vehicle
Year
Make
Model
Drivers Name, Address, Phone number
Enter any information available
Where did this incident happen? (Give Details, i.e.. Addresses -Intersections - Mile markers - Highway numbers)
If any, Enter any witnesses name.
Enter their contact information.
If any, Enter any witnesses name.
Enter their contact information.


"Click" only Once, this takes a few moments to send your information.