OUR OFFICEPO Box 261240, Plano, TX 75026

EMAIL USservice@ad-ga.com

CALL US+1 888 509 2342

FILE CLAIM

Complete the form below to report your insurance claim

View previously submitted claim

Insured Information

First Name *

Last Name *

Email *

Residence Phone

Business Phone

Cell Phone

Street Address

City

State

ZIP Code

Policy Information

Policy Number *

Loss Information

Date of Loss *

Time of Loss *

Location of Accident *

Description of Accident *

Authority Contacted

Report Number

Violations/Citations

Upload Damage Photos (Optional)

Upload photos of the damage to speed up your claim. The more documentation we have upfront, the faster we can process your payment.

Click to upload photos

JPEG, PNG, WebP, HEIC up to 10MB each

Driver & Vehicle Information

Driver's Name

Driver's License Number

Driver's Address

Driver's Phone Number

Driver's Relationship to Insured

Purpose of Use

Vehicle Used with Permission?

YesNo

Vehicle Details

Year

Make

Model

VIN

Damage Description

Estimate Amount

Vehicle Location

Vehicle Viewing Time

Other Insurance

Property Damage

Another Vehicle Damaged?

YesNo

Non-vehicle Property Damaged

Property Owner Name

Property Owner Phone

Property Owner Address

Property Damage Description

Property Insured?

YesNo

Injured Persons

Person 1

Location When Injured

Name

Age

Address

Phone

Extent of Injury

Witnesses

Witness 1

Location

Name

Age

Address

Phone

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