Report an Accident/Incident

Customer Information

Who is reporting this claim today?

Your Name

Your Address

Email (Enter if you wish to be contacted by email)

Best Contact Number

Discovery Information

Policy Number (PAN0999999)

Year, make, and model of the vehicle insured with Discovery?

Vehicle Identification Number of vehicle?

Who was driving the vehicle?

Who is the registered owner of the vehicle?

Accident Details

Date of Accident/Loss * (MM-DD-YYYY)

Time of Day (12:00 am/pm)

Where did this accident occur (i.e. highway, intersection, parking lot)?

Were the police were notified? If so, what Agency and Report number?

Were there any witnesses? If so, please list names and contact information.?

Describe in detail how the accident occurred.

Claimant Vehicle Information

Year, make, and model of the vehicle insured with Discovery?

Are you the registered owner? If not, who is the registered owner and their contact information.

Vehicle Damages?

Is the vehicle drivable? If not, where is the vehicle located?

2nd Claimant Vehicle Information (if applicable)

Year, make, and model of the vehicle insured with Discovery?

Are you the registered owner? If not, who is the registered owner and their contact information.

Vehicle Damages?

Is the vehicle drivable? If not, where is the vehicle located?

Property Damage

Was there any other property damaged (i.e. mailbox, fence, road sign, rail, etc.)?

If so, what property was damaged (i.e. mailbox, fence, road sign, rail, etc.)?

If so, please list property owners name and contact information.

Passenger Information

Name

Address

Best Contact Number

Email Address

Was the passenger injured?

If injured, was the passenger transported by ambulance?

Where was the passenger transported?

What type of injuries were sustained?

2nd Passenger Information (if applicable)

Passenger Name

Address

Best Contact Number

Email Address

Was the passenger injured?

If injured, was the passenger transported by ambulance?

Where was the passenger transported?

What type of injuries were sustained?

Additional Information

Notes/Comments

Please Read Before Submission: North Carolina General Statute 58-2-161 provides: any person who willfully and knowingly presents or causes to be presented a false or fraudulent claim or proof in support of such claim to an insurer for the payment of a loss…under an insurance policy or certificate of coverage, or prepares, makes or subscribes to a false or fraudulent proof of loss to an insurer with the intent that the same may be presented or used in support of such claim is subject to being charged with a felony and, if convicted, shall be punished as a Class H felony.

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