Rhode Island Independent Insurance Agent - Revens-Gates, Inc. Insurance

401-294-9537

Automobile Claim Information

To submit a claim directly to us, please complete the following form and click "Submit".

Auto Claim Form

Policy Holder Information
Contact Person Name
Contact Contact Phone
Contact E-mail

Policy Number
Policy Holder Name
Policy Holder Street Address
Policy Holder City
Policy Holder State, ZIP	ZIP

Accident Information
Date of Accident:
Time of Accident:
Location of Accident:
Brief description of accident:
Police contacted ?	yes no
Did injuries result from accident?	yes no

Damage Information
Insured Vehicle Year, Make & Model:
Brief Description of Damage:
Address where can vehicle be seen?
Please Give Additional Property Damage Information including name, address and vehicle information:
If Other Vehicle Damage Please Describe:

Thank you for your claim submission. We will process it as soon as possible and will contact you to confirm our reciept of your claim.