THIS
CLAIM IS:
An
Actual Claim where your auto has damage and / or you have received a bill, suit, call, notice seeking collection for damages
for
Reporting Purposes Only, whereas it could develop into the above. |
| WHO
IS TO BE LEAD CONTACT FOR FURTHER INVESTIGATION OR CLAIM
INFORMATION SAME
AS ABOVE |
| Lead
Contact Name:
Phone #:
Email: |
| CLAIM
INFORMATION |
| Date
of Claim:
Time of Claim:
AM
PM |
| Location
of the Claim (address or specific area): |
Description
of what happened?
|
If an
authority such as police, fire, was contacted, please name:
What is the report # of the authority, if known: |
| YOUR
VEHICLE & DRIVER INFORMATION |
| Vehicle
Year:
Make / Model:
VIN # (Last 4 Digits): |
| Full
Name of Driver:
Date of Birth:
License #:
State Licensed Issued In: |
| Sex: Male
Female Contact
Phone # for Driver:
or Contact
Above Lead Contact |
| What
is the driver's relationship to the vehicle? Owner
Employee
Family
Member Other |
| Was
the driver driving your vehicle with your permission? Yes
No |
| YOUR
VEHICLE'S DAMAGE - If NO DAMAGE Check
Here & Skip Section |
| Describe
Damage to Your Vehicle: |
| Estimate
of $ Amount of Damage:
or Not
Yet Known Do you have a written
Estimate? Yes
No |
| Where
can the damaged vehicle be seen (if needed by company)? |
| INFORMATION
ON THE PARTY WHICH COULD CLAIM DAMAGES |
| Type
of claim is, or could be: Damage
to Other's Vehicle(s) Damage
to Other's Property Bodily
Injury to Others |
| OTHER
VEHICLE OR PROPERTY DAMAGED INFORMATION - Complete All That is
Known |
| Vehicle
Year:
Make / Model:
VIN #:
License Plate #: |
| Describe
Property Damaged (Other Than Vehicle, If Any): |
Insurance
Company or Agent:
Policy #:
Company or Agent's Phone #: |
Owner's
Name:
Owner's Address:
Owner's Phone:
Owner's Email: |
Driver's
Name:
Driver's Address:
Driver's Phone:
Driver's Email: |
| Describe
Damage to Other Vehicle: |
| Estimate
Total $ of Damages Either for Property Damaged or Vehicle Damaged
or Both: |
| Where
can damage vehicle or property be seen?
or Contact
Claimant |
| INJURED
PARTIES |
| 1.
Name:
Address:
Phone:
Describe Injury: |
| 2.
Name:
Address:
Phone:
Describe Injury: |
| 3.
Name:
Address:
Phone:
Describe Injury: |
| 4.
Name:
Address:
Phone:
Describe Injury: |
| WITNESSES |
| 1.
Name:
Address:
Phone: |
| 2.
Name:
Address:
Phone: |
| 3.
Name:
Address:
Phone: |
| ADDITIONAL
NOTES / COMMENTS |
|
|