Connect · Report A Claim

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Report A Claim

To report a new claim on-line, please complete the form below. Note that some information is mandatory in order to complete the claim reporting process. Click on the Report Claim button when complete.

All fields marked with an asterisk (*) are required.

Person Reporting the Claim

*First Name

*Last Name

Email Address

*Best Contact Number

Work Phone Number

Cell Phone Number

Address (Street, City, State, Zip)

Year

Make

Model

Driver Name

Is the vehicle drivable?

yes no

Name, address, and phone number of repair shop or towing company (if applicable).

Policy Holder

Are you the policy holder?

First Name

Last Name

*Policy Number

Home Phone Number

Work Phone Number

Cell Phone Number

Address (Street, City, State, Zip)

Year

Make

Model

Driver Name

Is the vehicle drivable?

yes no

Name, address, and phone number of repair shop or towing company (if applicable).

Other Vehicle Involved in Accident

Year

Make

Model

Driver Name

Is the vehicle drivable?

yes no

Name, address, and phone number of repair shop or towing company (if applicable).

Accident Information

*Date of Accident

*Time of Accident

*Time Zone

*Street or Intersection

*City

*State

*Describe what happened. Be sure to list the names of any witnesses or injured passengers. Also describe any injuries which may have occurred.

*Accident Description

Additional Information

*Did the police respond?

This is required.

yes no

Police Agency

Police Report #

*Did an ambulance respond?

This is required.

yes no

*Were any citations issued?

This is required.

yes no

*Were there any injuries?

This is required.

yes no

*Were any vehicles towed?

This is required.

yes no

*Was weather a factor?

This is required.

yes no

Rain

Hail

Snow

Ice

Other

*Do you need a Spanish speaking representative?

This is required.

yes no

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About Us

Connect MGA LLC

PO BOX 260599

Plano, TX 75026

T: (888) 664-7127

Reliant General MGA LLC

PO BOX 260489

Plano, TX 75026

T: (866) 216-1151

Connect MGA LLC
PO BOX 260599
Plano, TX 75026
T: (888) 664-7127

Reliant General MGA LLC
PO BOX 260489
Plano, TX 75026
T: (866) 216-1151