Dealer Open Lot

REPORT A CLAIM

We appreciate the opportunity to adjust your loss. Our goal is to deliver best-in-class claims services with skill and accuracy. Please provide as much information as possible below and submit this form to get the hassle-free process started.

DOL

Reporting Party Information

Reporting Party Name(Required)

First Last

Reporting Party Phone Number(Required)

Email

Loss Detail Information

Date of Loss

Time Of Loss

Loss Type

Location of Loss

Street Address Address Line 2 City State ZIP Code

Description of Loss

Law Enforcement Details

Agency

Report Number

Issued Violations/Citations

If Yes, To Whom

Phone Number

Insured Detail Information

Policy Number

Insured Name

Address

Street Address Address Line 2 City State ZIP Code

Contact Name(Required)

Contact Phone(Required)

Contact Email(Required)

Agent Detail Information

Agency Name

Contact Name

Agent Contact Email

Agency Phone Number

Agency Contact Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Drivers

Insured Driver

Insured Driver Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Purpose of Use

Relationship To Owner

Claimant Driver

First Last

Claimant Driver Address

Street Address Address Line 2 City State ZIP Code

Claimant Vehicle

Claimant Insurance Company

Claimant Insurance Company Phone Number

Claimant Vehicle VIN

Claimant Vehicle Description

Claimant Insurance Policy

Insured Vehicle Information

Please fill out this document if there is more than one vehicle. DOWNLOAD DOCUMENT HERE

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Vin

Vehicle Color

Damage Description

Is Vehicle Drivable?

Vehicle Towed?

Towing Company Phone Number

Where Can the Vehicle Be Seen?

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Address

15301 Dallas Parkway, Ste 500
Addison, TX 75001

Phone

Toll Free: (844) 410-9201
Fax: (469) 252-1990

Email

info@appliedclaims.com
claimreportingDOL@appliedclaims.com

Fraud Reporting

Fraud Hotline: (800) 342-3504
fraudreporting@appliedclaims.com