Star Casualty Online Claim Form

Please complete the form below. If any of the required information (indicated by an * ) is not available, please type UNKNOWN except for required telephone numbers and zipcode. Click on the Report Claim button to start processing your claim. If you have any question(s), call us at 1-877-STAR-210.


Claim Reported By:  

Your Name:  

*

Your Phone Number:  

*

Best Calling Time:  

*

E-mail Address:  

*

 

Insured's Information:  

Insured Name:  

*

Insured Address:  

*

Policy Number:  

*

City:  

*

State/Province:  

Zip Code:  

*

Home Phone Number:  

*Minimum 1 Phone Number Required

Cell Phone Number:  

Work Phone Number:  

E-mail Address:  

 

Loss Information:  

Date of Loss:  

*

Time of Loss AM/PM:  

*

Police Report Case Number:  

*

Authorities Contacted:  

*

Violations/Citations:  

Accident Location:  

*

 

Accident Description:  

Accident Description:  

 

Driver Information:  

Driver Name:  

*

Address:  

*

Date of Birth:  

Driver License Number:  

Relation to Insured:  

Home Phone Number:  

Work Phone Number:  

 

Insured Vehicle:  

VIN#:  

*

Model:  

*

Make:  

*

Year:  

*

Tag Number:  

Is vehicle drivable?  

Was vehicle towed?  

Vehicle Location:  

Describe Damage:  

Towing Company:  

Towing Phone:  

 

Claimant 1 Information: Note: This section refers to the information of the person(s) you had the accident with.

Owner Name:  

*

Address:  

*

Owner Home Phone:  

Owner Work Phone:  

Best Calling Time:  

Driver Name:  

Address:  

Driver Home Phone:  

Driver Work Phone:  

Property Damage:  

 

Property Description:  

*

Vehicle Location:  

*

Describe Damage:  

*

Insurance Company:  

Policy Number:  

VIN#:  

Model:  

Make:  

Color:  

Year:  

Tag Number:  

Is vehicle drivable?  


 

Claimant 2 Information:  

Owner Name:  

*

Address:  

*

Owner Home Phone:  

Owner Work Phone:  

Best Calling Time:  

Driver Name:  

Address:  

Driver Home Phone:  

Driver Work Phone:  

Property Damage:  

 

Property Description:  

*

Vehicle Location:  

*

Describe Damage:  

*

Insurance Company:  

Policy Number:  

VIN#:  

Model:  

Make:  

Color:  

Year:  

Tag Number:  

Is vehicle drivable?  


 

Injured Persons:  

Injured Person No. 1:  

 

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

Age:  

Injury In Vehicle:  

Extent of Injury:  

Injured Person No. 2:  

 

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

Age:  

Injury In Vehicle:  

Extent of Injury:  

Injured Person No. 3:  

 

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

Age:  

Injury In Vehicle:  

Extent of Injury:  

Injured Person No. 4:  

 

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

Age:  

Injury In Vehicle:  

Extent of Injury:  

Injured Person No. 5:  

 

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

Age:  

Injury In Vehicle:  

Extent of Injury:  



 

Witness or Passenger:  

Witness or Passenger No. 1:  

 

Witness or Passenger:  

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

From Vehicle:  

Other:  

Witness or Passenger No. 2:  

 

Witness or Passenger:  

Name:  

*

Address:  

*

Phone:  

Cell Phone:  

From Vehicle:  

Other:  

 

 

Remarks:  

Remarks:  

 


 

 


 
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