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