First Insurance Company of Hawaii, LTD

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Your Auto Claim Form

Please complete the following claim form, noting mandatory fields are marked by asterisks. Once you submit your claim, we will reply back to you within one business day.

Policyholder Information

Policy Number *

Full Name of Policyholder *

Your Information

Your Name *

Your Relation to the Policyholder *

Street Address

Street Address2

City

State

ZIP Code

Phone Number *

Alternate Phone Number

Email Address

Description of Accident/Claim

Date of Accident/Claim *

Location of Accident/Claim *

Accident/Claim Description *

Description of Insured Vehicle Involved* (Year, Make, Model; VIN#; Plate#)

Driver of Insured Vehicle Name

Phone Number

Address

Driver’s License Number

Driver’s Relationship to Policyholder

Description of Damages to Insured Vehicle *

Was someone Injured? *

Yes
No, or none that you are aware of at time of reporting

If Yes, Name of Injured

Which Vehicle was the Injured Person in?

Contact Phone Number

Description of injury

Was there any Other Vehicle Involved? *

Yes
No

Description of Other Vehicle(s) Involved (Year, Make, Model; VIN#; Plate#)

Name of Other Vehicle Owner

Driver of Other Vehicle Name

Driver Phone Number

Other Driver Address

Driver’s License Number

Driver’s Relationship to Vehicle Owner

Description of Damages to Other Vehicle

Other Vehicle Insurance Carrier

Other Insurance Carrier Policy Number

Police report number

Any Other Comments or Notes

If you are unable to fill out the required fields as presented, you may file a claim with our claims reports desk associates at 808-527-7711 or via email at claimsreportdesk@ficoh.com

Submit Auto Claim

Let our local adjusters help you get back on the road

Your Auto Claim Form