United Security Insurance Company

Person Submitting Auto Accident Report

Name

Home Phone

Cell Phone

Do you consent to having United Security Insurance Company contact you about your claim via SMS/text messaging?

Yes, I consentNo, I DO NOT consent

Policy Number

Policy Holder Name

Policy Holder Address

Policy Holder City

Policy Holder State

Policy Holder ZIP Code

Policy Holder Home Telephone

Policy Holder Business Telephone

Policy Holder Cell Phone