## File a Claim

Claim submission progress

### Step 1 of 5 – Company Info

**20%**

### Reporting Party

- **Company Name** (Required)  
- **Company Address**  
  - Street Address  
  - Street Address 2  
  - City  
  - State  
    - Alabama  
    - Alaska  
    - American Samoa  
    - Arizona  
    - Arkansas  
    - California  
    - Colorado  
    - Connecticut  
    - Delaware  
    - District of Columbia  
    - Florida  
    - Georgia  
    - Guam  
    - Hawaii  
    - Idaho  
    - Illinois  
    - Indiana  
    - Iowa  
    - Kansas  
    - Kentucky  
    - Louisiana  
    - Maine  
    - Maryland  
    - Massachusetts  
    - Michigan  
    - Minnesota  
    - Mississippi  
    - Missouri  
    - Montana  
    - Nebraska  
    - Nevada  
    - New Hampshire  
    - New Jersey  
    - New Mexico  
    - New York  
    - North Carolina  
    - North Dakota  
    - Northern Mariana Islands  
    - Ohio  
    - Oklahoma  
    - Oregon  
    - Pennsylvania  
    - Puerto Rico  
    - Rhode Island  
    - South Carolina  
    - South Dakota  
    - Tennessee  
    - Texas  
    - Utah  
    - U.S. Virgin Islands  
    - Vermont  
    - Virginia  
    - Washington  
    - West Virginia  
    - Wisconsin  
    - Wyoming  
    - Armed Forces Americas  
    - Armed Forces Europe  
    - Armed Forces Pacific  
- **ZIP Code**  
- **Company Phone** (Required)

### Person Submitting Claim (Required)  
- **First Name**  
- **Last Name**  
- **Title**  
- **Relation to HDVI Insured** (Required)  
    - Third Party  
    - Other  
- **Phone**  
- **Email** (Required)  
- **Date Incident Occurred** (Required)  
  - MM/DD/YYYY  
- **Loss Location** (city, state) (Required)  
- **Description of Incident** (Required)  
- **Exposure** (Required)  
  - Vehicle  
  - Injured Person  
  - Property

### HDVI Insured Driver's Details (Required)  
- **First Name**  
- **Last Name**  
- **Company** (Required)  
- **Drivers License Number**  
- **Drivers License State**  
- **Date of Birth**  
  - MM/DD/YYYY  
- **Vehicle Make**  
- **Vehicle Model**  
- **Vehicle Year**  
- **VIN**  
- **Citation Received?**  
  - Yes  
  - No  
  - Unknown  
- **Towed?**  
  - Yes  
  - No  
- **Medical Transport?**  
  - Yes  
  - No  
  - Unknown  
- **Description of Damage**

### 3rd Party Driver's Details (Required)  
- **First Name**  
- **Last Name**  
- **Company** (Required)  
- **Drivers License Number**  
- **Drivers License State**  
- **Date of Birth**  
  - MM/DD/YYYY  
- **Vehicle Make**  
- **Vehicle Model**  
- **Vehicle Year**  
- **VIN**  
- **Citation Received?**  
  - Yes  
  - No  
  - Unknown  
- **Towed?**  
  - Yes  
  - No  
- **Medical Transport?**  
  - Yes  
  - No  
  - Unknown  
- **Description of Damage**

### Notifications

**Step 1 of 5, Company Info**