PRODUCERS ENTER HERE CONSUMER MAKE A PAYMENT REPORT A CLAIM DOWNLOAD FORMS ABOUT US CAREERS CONTACT REPORT A CLAIM BASIC RESPONSIBILITIES FOR ANYONE INVOLVED IN A LOSS REGARDLESS OF FAULT Contact the proper law enforcement agency immediately Obtain information on all parties and damages involved Take action to protect and mitigate your damages Refer to your insurance policy Contact American Freedom claims immediately 847-758-9300 EXT. 3 FRAUD WARNING: Any person who knowingly and with an intent to injure, defraud or deceive any Insurer, files a statement of claim or an application obtaining any false, incomplete or misleading information is guilty of a felony of the third degree. RESPONSIBILITIES OF ANY PERSON INVOLVED IN AN ACCIDENT, GUILTY OR NOT Contact law enforcement agency Obtain information on all the people involved and all the damages Take action to protect and mitigate your damages Check your insurance policy Contact American Freedom's claims department immediately at 847-758-9300 EXT. 3 FRAUD WARNING : Any person who knowingly and with intent to injure, defraud or mislead any insurer, files a statement of claim or a request to obtain a false, incomplete or misleading claim is guilty of a felony of the third degree. I acknowledge that I have read and understand the above (required) / I acknowledge that I have read and understand the above (required) * Policy Number of American Freedom Insurance / Policy Number of American Freedom Insurance Incident Information Date of Incident/Fecha del Incidente:* Time HH : MM AM PM Time Zone CST - Central Time EST - Eastern Time Incident Street Address/Direccion del Incidente: Street Address/Numero y calle City/Ciudad State/Estado ZIP / Postal Code/ Codigo Postal American Freedom Driver Information Name/Nombre:* First Name/Primer Nombre Last Name/Apellido Driver's License #/Numero de Licencia de manejo: Address/Domicilio:* Street Address/Numero y calle City/Ciudad State/Estado ZIP / Postal Code/ Codigo Postal Phone/Telefono: Email/Correo Electronico: Vehicle Year/Vehiculo Año: Vehicle Make/Vehiculo Marca: Vehicle Model/Vehiculo Modelo: Disposition/Disposición: Drivable/Se puede manejar Non-drivable/No operable Other Driver Information/Informacion del otro conductor Other driver's Name First/Primer Nombre Last/Apellido Address/Direccion Street Address/Numero y calle City/Ciudad State/Estado ZIP / Postal Code/ Codigo Postal Phone/Numero Telefonico: Email/Correo Electronico: Insurance Company/Compania de suguro Policy Number/numero de poliza Other Vehicle Year/Vehiculo Año: Vehicle Make/Vehiculo Marca: Vehicle Model/Vehiculo Modelo: Description of Incident/descripción del accidente Rear End/Golpe tresero Intersection/Intersección Side Swipe/Golpe de lado a lado Cross Over/Cambio de carril Parked Car/Vehiculo estacionado Parking Lot/Estacionamiento Animal/Animal Theft/Robo Fire/Incencio Other/Otro Please Describe in detail what happened/Describa con detalle como ocurrio: Police on the scene?/Llego la policia a la escena? Yes/Si No/No Police Department/Departamento de Policia: Police Report #/Numero de Reporte: Does anyone claim to be injured?/Llego la policia a la escena? Yes/Si No/No If yes, provide their names and contact information/En caso afirmativo, provea sus nombres e infomacion de como contactarlos: Name of person completing form/Nombre de la persona que lleno esta forma First/Primer nombre Last/Apellido Relation to American Freedom Insured/Relacion al asegurado de American Freedom Self/Mismo Claimant/Reclamante Agent/Agente Attorney/Abogado Carrier/Compania de seguros Other/Otro Phone Number/Numero Telefonico Email Address/Correo Electronico If available, please upload police report and/or pictures of damages vehicles and/or property. Si disponible, favor de subir copia del reporte de policia y/o fotos de los vehiculos danados y/o propiedad File Drop files here or STORAGE/TOWING/COOPERATION NOTICE / Almacenamiento/ grua/ aviso de cooperación* You must protect your vehicle and mitigate your damages. If your vehicle is not drivable, you are requested to contact us immediately for further instructions to avoid additional towing and storage fees. You are urged to release your vehicle from any towing/storage facility and make arrangements to have it moved to a storage free facility. Should additional expenses arise as a result of your vehicle being at its current locations (storage charges, difference in labor, parts, removal of salvage, unauthorized repairs etc.) you may be responsible. American Freedom reserves the right to investigate all claims. Submitting this form does not imply or confirm coverage for any loss. Per the terms and conditions of the American Freedom policy, you are required to cooperate in the investigation of any claim. Failure to cooperate may result in a denial of coverage. Please contact our Claim Department at tel.# 847-758-9300 or email: claims@americanfreedomins.com for further assistance. Usted debe proteger su vehículo y mitigar sus daños. Si su vehículo no se puede conducir, usted debe contactarse con nosotros inmediatamente para recibir más instrucciones a fin de evitar remolques adicionales y costos de almacenamiento. Por favor haga que su vehículo sea remolcado a un lugar de almacenamiento gratuito. Si se acumulan gastos adicionales como resultado de que el vehiculo se mantenga en la locacion actual (cargos de almacenamiento, costos de reparaciones que excedan nuestros costos de reparacion, partes, reparaciones no autorizadas, etc.) usted puede ser responsible. American Freedom reserva los derechos a investigar todos los reclamos. Sometiendo este documento no impilca o confirma covertura para ningun accidente. Base a los termininos y condiciones de la póliza de American Freedom, usted esta requerido a cooperar en la investigación de cualquier reclamo. Falla a cooperar puede resultar en la negación de covertura. Por favor contacte a nuestro departamento de reclamos al numero de telefono: 847-758-9300 o correo electronico: claims@americanfreedomins.com para asistencia adicional. I acknowledge that I have read and understand the above (required)/reconozco que he leído y entiendo lo anterior (requerido) Producers Enter Here Make a Payment Español Careers Proud Supporter Find a Broker Privacy Policy American Freedom Insurance Company 1699 Wall St, Suite # 600 Mount Prospect, IL 60056 Phone: (847) 758-9300 | Fax: (847) 758-9685 info@americanfreedomins.com Copyright © 2018, American Freedom Insurance Company | Privacy Policy