Auto Defense Referral Submission Auto Defense Renewal "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Referrer’s Contact InformationFull Name of Insurer*Date of Referral* MM slash DD slash YYYY Claim Number*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneExtensionNew Loss InformationDate of Loss MM slash DD slash YYYY Loss LocationBrief Description of LossInclude names and contact information for any known witnesses.Type of Loss - Check all that apply Bodily Injury Property Damage Description of InjuryWas this a multi-vehicle accident? Yes No Description of Property DamageIs there a police report? Yes No Please upload the police report with the claim file documents.Insured/Policyholder InformationFull Insured/Policyholder Name*Contact PersonAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneExtensionAdverse Party’s InformationFirst Name* First Last Name* First Contact PersonPhoneExtensionEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Counsel Representing Adverse PartyName of AttorneyFirm NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneExtensionEmail DamagesAmount of Damages Claimed (if known)What are the policy limits?What is the deductible?Upload File Documents Drop files here or Select files Max. file size: 50 MB. CommentsImportant Notice Regarding Case Referral SubmissionsSubmitting information through this online referral form does not establish an attorney-client relationship between you and DSB&C or any of our attorneys. Please do not include confidential or sensitive information in your submission until you have spoken directly with one of our attorneys and formally established a privileged attorney-client relationship. If you are not presently a client of DSB&C, any information you provide through this form may not be protected by attorney-client privilege. This referral portal and our invitation to contact us should not be interpreted as a solicitation for legal services or as creating any attorney-client relationship. Additionally, this should not be construed as confirmation that our attorneys are available to provide legal representation in jurisdictions where they are not licensed to practice law. By completing and submitting this referral form, you acknowledge that you have read, understood, and agree to these terms and conditions.
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