Striker

If you have ANY information regarding a potential claim, please go ahead and report whatever information you have (even if it is incomplete). The sooner claims are reported, the quicker ACG can start the investigation.

Customer Information

Client Name
Time of Loss Event
:
MM slash DD slash YYYY
MM slash DD slash YYYY

Insured Information

Insured Contact
Insured Address

Description of Loss

Witness Name
Witness Address
Witness Name (2)
Witness Address (2)
Witness Name (3)
Witness Address (3)

Description of Auto(s)/Equipment Involved

Max. file size: 96 MB.

Description of Reported Injuries

Insured Party 1
Address
Insured Party 2
Address
Insured Party 3
Address

Additional Enclosures

Max. file size: 96 MB.
Emergency Services on Scene

Person Reporting Loss

MM slash DD slash YYYY

Please upload any additional information you have (i.e. police report, vehicle estimates, photos, contracts, etc.)

Max. file size: 512 MB.

If you have any issues with submitting this claim form, please contact us at 1-800-337-8131 or e-mail us at claimreportingredstone@appliedclaims.com.