Report Auto Claim

You may use this convenient online form to report a claim. All fields marked with an asterisk (*) are required fields.

Click here to print a state Motor Vehicle Operator Report.

Insured Personal Details

* First Name:
* Last Name:
Street:
City:
State:
Zip:
Day Phone:
Evening Phone:
Email:
License #:
The best way to reach me is:

Claim Details

Who was the driver of the vehicle?
Date of accident:	(mm/dd/yyyy)
Time of accident:

Where did the accident occur?:
Street:
City:

Vehicle Information:
Year:
Make:
Model:
Plate #:

What happened in the accident?

Other Driver Information:
First Name:
Last Name:
Street:
City:
State:
Zip:
Day Phone:
Evening Phone:
License #:

Other Vehicle Information:
Year:
Make:
Model:
Plate #:

Pedestrian Information (if applicable):
First Name:
Last Name:
Street:
City:
State:
Zip:
Day Phone:
Evening Phone:

Witness Information (if applicable):
First Name:
Last Name:
Street:
City:
State:
Zip:
Day Phone:
Evening Phone:

Other Information or Details:

Johnson and Rohan Insurance
50 Salem Street ~ P.O. Box 52 ~ Lynnfield, Massachusetts 01940
Phone: 1-800-491-1414 or 1-781-224-0909 ~ Fax: 1-781-224-0546
E-Mail: info@JohnsonandRohan.com