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

    Wallaceburg Office

    403 Wellington St.
    Wallaceburg, ON N8A 2Y2

    Phone: 519-627-1777