LOUIS A WILLIAMS
Personal Auto LOUIS A WILLIAMS Customer Services


Person Reporting the Claim
  Your First Name: *
  Your Last Name: *
  Are you the: Insured   Other Party   Neither
  Your Cell Phone#: *
  Other Contact Phone#:
  Your Email Address: *
  Your Address: *
  Your City, State & Zip: *    

Insured Information
  Policy Number:
  Insured's First Name:
  Insured's Last Name:
  Insured's Cell Phone#:
  Other Contact Phone#:
  Driver's First Name: *
  Driver's Last Name: *
  Driver's Phone#: *
  Insured Vehicle: *
  Describe Damage: *
  Describe Injuries: *

Other Vehicle in Accident
  Driver's First Name:
  Driver's Last Name:
  Driver's Cell Phone#:
  Driver's Other Phone#:
  Vehicle Description:
  Describe Damage:
  Describe Injuries:

Other Important Information
  Date of Accident: *
  Time of Accident: *
  Accident Location: *
  Describe what happened: *
  Was there a police report? *
  Additional Information:

Upload a photo of damages.

On submit look for success message to verify e-mail was sent.
If no success message limit amount of pictures to 4 or less.