Submit A Claim

Submitting a claim is as easy as answering the question below and then filling out the form that follows.

Are you insured with American Alliance?
YesNo

Basic Information


Your Contact Information















Driver of Vehicle Information







Owner of Vehicle Information






Purpose of Operation at time of Accident:

Weather:

Was operation of vehicle with permission of owner? YesNo
Is your vehicle ever used for paid ride share services such as Uber, Lyft or a similar ride share service? YesNo
Name of Service:
When did you start with this service?
Were you driving for this service at the time of loss: YesNo

Description of Accident

Accident Type:











Was there intoxication involved? YesNo
Did the police respond? YesNo
Was a police report made? YesNo

Was a ticket issued? YesNo

Did an ambulance respond? YesNo
Were there injuries to the Insured? YesNo

Were there injuries to the Claimant? YesNo


Storage Addendum

It is our understanding that your vehicle has been involved in an accident. It is in your best interest to pay any accruing charges and have your vehicle released immediately from any towing and/or storage facility and then have it moved to your residence, body shop or any other place where it will not accrue any additional expenses.

Should additional expenses arise as a result of your vehicle being at its present location (ie storage charges, difference in labor, parts, removal of salvage, etc.) please be advised that you may be responsible for those expenses. In the event that you wish to move your vehicle at a later date, you may be responsible for any and all storage charges.

Please contact our claims department at (847) 916-3200 Monday through Friday between the hours of 8:30 a.m. and 4:30 p.m., if you have further inquiries.

I acknowledge that I have read and understand the above (required)

Rental Reimbursement Notice

Please be advised our company has a rental reimbursement agreement with Hertz for a rate of $23.99 per day.
If rental is approved for your claim, you are to submit a copy of the paid invoice to our office via email, mail or fax
Attn: (claim number)
To access this rate provide code number: 2144219 to any Hertz facility.
Please note reimbursement will be based on reasonable repair time

I acknowledge that I have read and understand the above (required)

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