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Person Submitting Auto Claim
Full Name
Home Phone
Cell Phone (optional)
Do you consent to having West Virginia National Auto Insurance Company contact you about your claim via SMS text messaging?
Are you the policyholder?
Vehicle
Year
Make
Model
Driver
Full Name
Address
City
State
ZIP code
Home Phone
Cell Phone (optional)
Business Phone (optional)
Tell Us About the Accident
Date of Accident
Time of Accident
Location of Accident
How did the accident happen?
Was vehicle used with owner's permission?
Is the vehicle drivable?
Was the vehicle stolen?
Was the theft or accident reported to the police?
Damage
Was there any damaged property?
Injuries
Were there any injuries?
Witnesses
Were there any witnesses?
Occupants
Were there any occupants in the insured vehicle?
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