Automobile Accident Report

If this accident caused serious injury or death, please do not use this online form to report the claim. Instead, call us immediately at (800) 554-2642, then select menu Option 2.



Step 1

In order to handle your claim properly, your message and the information in it may need to be shared with agents or employees within the Church Mutual organization. We may also share the information with others who perform a business, professional, or insurance function for our company. By sending your message to Church Mutual you acknowledge that your message and any information in it may be reproduced or shared with agents, employees or others acting on behalf of Church Mutual without limitation.

Messages sent over the Internet may not be secure. By using this form, you acknowledge that Church Mutual is not responsible for any information contained in this form which may be read or intercepted by unintended third parties.

In Step 1 you are asked to indicate the number of people in your vehicle and in the other vehicle and to indicate the number of witnesses to the accident. Your responses to these questions will generate the appropriate number of reporting boxes and will simplify the reporting process for you.

You might not know all of the information that is requested of you in the online form. We understand that. Simply provide the information you do know and leave other entry boxes blank.

How many people (if any) were in your vehicle at the time of the accident? (If it is more than 15, please report the claim by telephone.)
None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Was there damage to your vehicle?
No Yes

How many people (if any) were in the other vehicle at the time of the accident? (If there were more than 15, please report the claim by telephone.)
None Don't Know 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

How many other vehicles were damaged in the accident?
None 1 2 3 4 5

Was there damage to someone else's property, other than a vehicle? (For example, a sign, pole, bicycle, tree, or house.)
No Yes

How many pedestrians (if any) were injured? (If there were more than 15, please report the claim by telephone.)
None Don't Know 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

How many witnesses (if any) were there to the accident, other than persons who were occupants of either vehicle? Include only those individuals you can list by name.
None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15