Claim Form

Contact Information

First Name

Last Name

Daytime Phone

E-Mail Address

Policy Holder Information

Policy Number

Check this if Policy Holder matches Contact Person

Policy Holder - Name

Policy Holder - Phone

Policy Holder - Address

Policy Holder - City

Policy Holder - State      Zip Code

Accident Information

Date of Accident    / /

Time of Accident    AM  PM

Check this if Accident Location matches Policy Holder Address

Accident Location - Address

Accident Location - City

Accident Location - State      Zip Code

Brief Description of the Accident:

Police/Fire Contacted    Yes     No

Police/Fire Report Number

Police/Fire Department Name

Any Witnesses Present    Yes     No

Did Injuries Result from Accident    Yes     No

If "Yes" to above, please provide:
Name, Address, Phone Number, and Extent of Injuries of those Injured.

Damage Information

Was Policy Holder Vehicle Damaged    Yes     No

If "Yes" to above, please provide the following:

Vehicle Year

Vehicle Make

Vehicle Model

Brief Description of Damage

Where can the Vehicle be seen

If other Vehicles Damaged please Describe

Please Describe Additional Property Damage

The foregoing is a true statement of the cause and estimated amount of this loss. If approved by the Company, I/we agree to accept this amount in settlement.

Before submitting this report, make sure that all questions have been fully answered, thereby enabling the company to serve you better in conjunction with your reported loss.