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ARI Insurance Companies
133 Franklin Corner Road
Lawrenceville, NJ 08648

Phone: 609-882-7500
Fax: 609-882-4088

In the event of a disaster (click here)
Report a Claim

Asterisks(*) denote required information for this report to be properly processed.

Policyholder Information
ARI Policyholder Name:*
Contact Name (Last, First):*
Policy Number:
Policyholder Street:
City:
State:
Zip Code:
Phone Number:
-- Ext:
  
Accident Information
Type of Loss:
Record Only Actual Claim
Accident Date:*
Time:
 AM PM
Location of Accident:
Address:
City:
   State:
   Zip Code:
Description of the accident*:
Were police called?:
Yes No
If so, Department Name:
Report Number:

Policyholder Vehicle Information
Year:
   Make:
   Model:
Vehicle Identification Number:
License Plate Number:
If applicable, was policyholder vehicle damaged?:
Yes No
If "Yes" to above, area of damage:
Name of Driver (Last, First, MI):
Daytime Phone Number:
-- Ext:
Please give Name(s) of Passenger(s):
  
Other Vehicle Information
Year:
   Make:
   Model:
License Plate Number:
Area of Damage:
Name of Driver (Last, First, MI):
Address (Driver):
Street Address or PO Box:
City:
  State:
 Zip Code:
Home Telephone Number
--
Work Telephone Number:
-- Ext:
Drivers License Number:
Owner:
Please give Name(s) of Passenger(s):
Insurance Company:
Policy Number:

Injury Information
Were there any injuries?:
Yes No Unsure
Was anyone transported to a hospital?:
Yes No
Provide name(s), address(es), phone number(s), extent of injuries, and the name of the medical facility:
Was the injured party... (check all that apply):
in policyholder vehicle in other vehicle pedestrian
Extent of Injuries:
  
Witness Information
Were there any witnesses present?:
Yes No
If "Yes", please provide name(s), address(es), and phone number(s):

Other Information
If something other than a vehicle was damaged, please describe:
Other important claim information or comments:
Name of Person Completing Report*:
  Policyholder Other Vehicle Agent Other
E-mail address:

 
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