Submit A Claim

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

Please select ONE of the following:*

I am insured with American Alliance

I was involved in a loss with someone insured with American Alliance

Other – Party not involved in the loss (agents, carriers etc.)

Basic Information

Policy Number*

Date of Accident*

Time of Accident*

American Alliance Driver's Information

Parked Vehicle

Not Applicable - Parked Vehicle

Driver's Name*

Driver's Date Of Birth*

Driver's License Number*

Driver's Date Of Birth

Driver's License Number

Driver's Address*

Driver's Address

Driver's Phone Number*

Driver's Email Address

Driver's Phone Number

Driver's Email Address

American Alliance Vehicle Information

Year, Make & Model of Vehicle Driven at Time of Loss*

Vehicle Point of Impact*

Is the Vehicle Drivable?*

Yes

No

Is the Vehicle Drivable?

Yes

No

Provide Location of Vehicle

Vehicle Owner

Owner Same as Driver

Owner's Name*

Owner's Name

Owner's Date of Birth*

Owner's Driver's License Number*

Owner's Date of Birth

Owner's Driver's License Number

Owner's Address*

Owner's Address

Owner's Phone Number*

Owner's Email

Owner's Phone Number

Owner's Email

Is your vehicle ever used for Paid Ride Share Service such as Uber, Lyft or a similar ride share or delivery service?*

Yes

No

Name of Service*

When did you start with this service?*

Were you driving for this service at the time of the loss?*

Were you logged into this service's platform at the time of the loss?*

When was the last time you drove for this service?*

Are you currently still registered with this service?*

Yes

No

Please add all other parties involved

Not Applicable – Single Car Loss

Other Driver's & Vehicle Information

Driver's Name*

Driver's Phone Number*

Driver's Email

Driver's Address*

Year, Make & Model of Driver's Vehicle*

Vehicle Point of Impact*

Insurance Carrier

Policy or Claim Number

Owner of Other Car

Owner Same as Driver

Owner's Name

Owner's Phone

Owner's Email

Owner's Address

Your Vehicle Information

Driver's Name*

Driver's Phone Number*

Driver's Email

Driver's Address*

Year, Make & Model of Driver's Vehicle*

Vehicle Point of Impact*

Is the Vehicle Drivable?*

Yes

No

Provide Location of Vehicle

Insurance Carrier*

Policy or Claim Number*

Owner of Other Car

Owner Same as Driver

Owner's Name*

Owner's Phone*

Owner's Email

Owner's Address*

Please Add All Other Parties

Driver's Name*

Driver's Phone Number*

Driver's Email

Driver's Address*

Year, Make & Model of Driver's Vehicle*

Vehicle Point of Impact*

Is the Vehicle Drivable?

Yes

No

Provide Location of Vehicle

Insurance Carrier

Policy or Claim Number

Owner of Other Car

Were there any passengers inside your vehicle at the time of the loss?*

Yes

No

Were there any passengers inside your clients vehicle at the time of the loss?*

Yes

No

Passengers' Information*

Please add passenger info (up to 8)

First & Last Name

Date of Birth

License Number

Address

Were there any passengers inside any of the other vehicles at the time of the loss?*

Yes

No

Unknown

Please add any contact info:

Name of Person Completing Form*

Email Address*

Enter Email Address below to receive confirmation of your Claim Submission & Next Steps

Phone Number*

Company/Agency Name*

Your Claim/Reference Number*

Submit A Claim

Basic Information

American Alliance Driver's Information

American Alliance Vehicle Information

Other Driver's & Vehicle Information

Your Vehicle Information

Please Add All Other Parties

Additional Vehicles

Additional Vehicle #1

Additional Vehicle #2

Additional Vehicle #3

Additional Vehicle #4

Additional Vehicle #5

Description of Accident

Passengers Information

Customer Area

Submit A Claim

Basic Information

American Alliance Driver's Information

American Alliance Vehicle Information

Other Driver's & Vehicle Information

Your Vehicle Information

Please Add All Other Parties

Additional Vehicles

Additional Vehicle #1

Additional Vehicle #2

Additional Vehicle #3

Additional Vehicle #4

Additional Vehicle #5

Description of Accident

Passengers Information

Producer Login

Customer Area