Auto Claim Form

   Back to CLAIM FORMS Page Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  
ALL RIGHTS RESERVED

Auto Claim Form

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-  This form is intended for Auto Claims. If the claim does not involve an auto, please use either the General Liability or Property Claim Forms.

GENERAL INFORMATION

Your Account Name:

 Phone: Type: Cell  Business  Home

City, State

State:

 Fax:

Person Completing Form:

 Email:
 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 #:Cell  Business  Home    Email:
 CLAIM INFORMATION
 Date of Claim:  Time of Claim: AM  PM
 Location of the Claim (address, city, state 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
 Was your driver injured? Yes   No    Were there passengers injured in your vehicle? Yes   No
 Was the other vehicle's driver injured? Yes   No    Were there passengers injured in the other vehicle? Yes   No  
 Were there injuries to persons outside of the vehicles? Yes   No  
 WITNESSES
 1. Name:  Address:   Phone:
 2. Name:  Address:   Phone:
 3. Name:  Address:   Phone:
 ADDITIONAL NOTES / COMMENTS

 
!!!  IMPORTANT  !!!

 ITEMS TO CONSIDER FOR ALL CLAIMS
 1. Do not admit fault.  It is for the insurance company(s) to decide who is at fault after investigation.
 Hold supporting documents (police reports, pictures, witness statements, etc)
 Your insurance company adjuster will request them if needed.
 

QUESTIONS / HELP

 

Office Email:

 insurance@thompsongusic.com

Office Phone:

 (412) 271-8888  (9-4:30 EST)

Office Fax:

 (877) 271-8898

 

 CREATED 6/00 by
T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: September 04, 2019 .