If your accident involves serious injury, or otherwise requires immediate attention, please call our office at (207) 799-5541 or (800) 373-5541, 24 hours a day, 7 days a week.

Your Account Information

Policyholder's Name:

Daytime Phone number:

Your email address:

Accident Details

Driver's Name:

Year / Make of Your Vehicle:

Date and Time of Accident:

Location of Accident:

Please describe the accident:

Please describe any damage to your vehicle, and any injuries:

Police Report Filed?

Name of Police Dept.:

Information About the Other Vehicle:

Owner's Name:

Owner's Address:

Owner's Phone Number:

Driver's Name:

Driver's Phone Number:

Other Driver's Ins. Company:

Please describe any damage to the other vehicle, and any injuries:

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© Noyes Hall & Allen Insurance
170 Ocean Street 
South Portland, ME  04116-2403 
(207) 799-5541    (800) 373-5541
Maine Resident Producer Agency #AGR29506