Claim Reported By:
Your Name:
*
Your Phone Number:
*
Best Calling Time:
*
E-mail Address:
*
Insured's Information:
Insured Name:
*
Insured Address:
*
Policy Number:
*
City:
*
State/Province:
Zip Code:
*
Home Phone Number:
*Minimum 1 Phone Number Required
Cell Phone Number:
Work Phone Number:
E-mail Address:
Loss Information:
Date of Loss:
(month)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
(date)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(year)
2008
2009
2010
2011
2012
2013
2014
2015
*
Time of Loss AM/PM:
*
Police Report Case Number:
*
Authorities Contacted:
*
Violations/Citations:
Accident Location:
*
Accident Description:
Accident Description:
Driver Information:
Driver Name:
*
Address:
*
Date of Birth:
Driver License Number:
Relation to Insured:
Home Phone Number:
Work Phone Number:
Insured Vehicle:
VIN#:
*
Model:
*
Make:
*
Year:
*
Tag Number:
Is vehicle drivable?
(choose one)
Yes
No
Was vehicle towed?
(choose one)
Yes
No
Vehicle Location:
Describe Damage:
Towing Company:
Towing Phone:
Claimant 1 Information: Note: This section refers to the information of the person(s) you had the accident with.
Owner Name:
*
Address:
*
Owner Home Phone:
Owner Work Phone:
Best Calling Time:
Driver Name:
Address:
Driver Home Phone:
Driver Work Phone:
Property Damage:
Property Description:
*
Vehicle Location:
*
Describe Damage:
*
Insurance Company:
Policy Number:
VIN#:
Model:
Make:
Color:
Year:
Tag Number:
Is vehicle drivable?
(choose one)
Yes
No
Claimant 2 Information:
Owner Name:
*
Address:
*
Owner Home Phone:
Owner Work Phone:
Best Calling Time:
Driver Name:
Address:
Driver Home Phone:
Driver Work Phone:
Property Damage:
Property Description:
*
Vehicle Location:
*
Describe Damage:
*
Insurance Company:
Policy Number:
VIN#:
Model:
Make:
Color:
Year:
Tag Number:
Is vehicle drivable?
(choose one)
Yes
No
Injured Persons:
Injured Person No. 1:
Name:
*
Address:
*
Phone:
Cell Phone:
Age:
Injury In Vehicle:
(choose one)
Insured Vehicle
Pedestrian
Claimant 1
Claimant 2
Claimant 3
Extent of Injury:
Injured Person No. 2:
Name:
*
Address:
*
Phone:
Cell Phone:
Age:
Injury In Vehicle:
(choose one)
Insured Vehicle
Pedestrian
Claimant 1
Claimant 2
Claimant 3
Extent of Injury:
Injured Person No. 3:
Name:
*
Address:
*
Phone:
Cell Phone:
Age:
Injury In Vehicle:
(choose one)
Insured Vehicle
Pedestrian
Claimant 1
Claimant 2
Claimant 3
Extent of Injury:
Injured Person No. 4:
Name:
*
Address:
*
Phone:
Cell Phone:
Age:
Injury In Vehicle:
(choose one)
Insured Vehicle
Pedestrian
Claimant 1
Claimant 2
Claimant 3
Extent of Injury:
Injured Person No. 5:
Name:
*
Address:
*
Phone:
Cell Phone:
Age:
Injury In Vehicle:
(choose one)
Insured Vehicle
Pedestrian
Claimant 1
Claimant 2
Claimant 3
Extent of Injury:
Witness or Passenger:
Witness or Passenger No. 1:
Witness or Passenger:
(choose one)
Witness
Passenger
Name:
*
Address:
*
Phone:
Cell Phone:
From Vehicle:
(choose one)
Insured
Other
Other:
Witness or Passenger No. 2:
Witness or Passenger:
(choose one)
Witness
Passenger
Name:
*
Address:
*
Phone:
Cell Phone:
From Vehicle:
(choose one)
Insured
Other
Other:
Remarks:
Remarks: