Report a Claim

What to do in the event of an Accident:

If anyone is injured, immediately render any possible first aid assistance and call emergency services.
Cooperate fully with the police, but do not make any admissions about your liability. Do not sign any statements for anyone other than an authorized representative of your insurance company.
If possible exchange names, addresses, and insurance information with the driver of the other vehicle.
Report the accident to the nearest police station and pick up the police report.
Fill out as much information below and your Next Century Insurance Claims Representative will begin drafting your MV-104 Report.

Vehicle #1

Registrant Information
First Name
Last Name
Street Address
Street Address 2
City
State / Province / Region
Postal / Zip Code
Country
Plate Number
State of Registration
Vehicle Year & Make
Vehicle Type
Insurance Company
Policy Number
Estimated of Property Damage
How many people in the vehicle?
Accident Date
MM slash DD slash YYYY
Accident Time

: HH

MM

AM/PM
Did Police investigate at the scene?
By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim. Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.