File an Auto Claim






DPM Insurance Group Office Location

Name of Your Broker


Policy Holder Information

Policy Number

Name of Policy Holder*

Home Phone*

Work Phone

Where should we contact you?

Best time to contact you?


Accident Information

Date of Incident*

Time of Incident*

Location of Incident*

Who was driving?

Vehicle Year

Vehicle Make

Vehicle Model

Is the vehicle drivable? YesNo

If the vehicle is not drivable, where can it be inspected?

Please provide as much detail as possible regarding the claim in the spece provided below. A representative will contact you shortly.

Did any injuries arise from the accident? YesNo

If yes, please provide names, addresses, phone numbers and the extent of the injuries:

Other Driver Information

Full Name

Insurance Provider

Policy Number

Contact Phone

License Plate Number

Vehicle Year

Vehicle Make

Vehicle Model


Location of Accident

City

Province:

Police Contacted? YesNo

Officer's Name

Officer's Badge Number

Were there witnesses? YesNo


Witness Information

Full Name

Contact Phone

WorkPhone

Email Address


Form Completion

Blenheim Office

24 Marlborough St. N., Box 479
Blenheim, ON N0P1A0

Phone: 519-676-8159
Fax: 519-676-0020

Chatham Office

250 St. Clair St.
Chatham, ON N7L 3J9

Phone: 519-352-4343
Toll Free: 1-800-561-4949
Fax: 519-352-6484

Essex Office

29 Talbot St. N, Box 69
Essex, ON N8M 2Y1

Phone: 519-776-6457
Fax: 519-776-7400

Harrow Office

65 King St. W., Box 790
Harrow, ON N0R 1G0

Phone: 519-738-2277
Fax: 519-738-2279

Tilbury Office

59 Mill St. E, Box 1239
Tilbury, ON N0P 2L0

Phone: 519-682-0202
Fax: 519-682-2391