Step 1 of 3 33% Date MM slash DD slash YYYY Name First Last Email example@example.com Phone NumberFax NumberCompany Name Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Policy NumberEffective Start Date MM slash DD slash YYYY Effective End Date MM slash DD slash YYYY Claim # Date of Loss MM slash DD slash YYYY Time of Loss Hours : Minutes AM PM AM/PM Email example@example.com INSUREDInsured Name First Name Last Name Insured Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured Residence Phone NumberPerson to Person ContactBusiness Phone NumberContact Phone Number FactsLocation of Loss Description of Loss or AccidentPolicy InformationBodily Injury Property Damage Combined Single Limit Medical Payments Comprehensive Deductible Collision Deductible Other Deductibles Loss Payee(if none, so indicate) Insured Vehicle (if Auto Loss)Vehicle # Year Make Model Plate # VIN # Owners Name First Name Last Name Owners Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Owners Phone NumberDrivers Name Drivers Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Drivers Phone NumberRelation To insured Drivers License Date of Birth MM slash DD slash YYYY Describe DamageRepair Estimate Where can Vehicle be seen? When? Claimant Property DamageDescription Other Vehicle or Property Insured? Yes No Company or Agency Name Policy # Owner/ Claimant First Name Last Name Owners Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Drivers Name First Name Last Name Driver is the same as Owner Yes No Drivers Phone NumberDescribe DamageEstimate amountWhere can Vehicle be seen More than one adverse vehicle? Yes No (If yes, please include information under "Further Information or Instructions" below) Injured Parties (Insured or Claimant)#1 Name First Name Last Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone NumberAgeInjured Party #1PedestrianInsured VehicleAdverse VehicleExtent of Injury #2 Name First Name Last Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone NumberAgeInjured Party #2PedestrianInsured VehicleAdverse VehicleExtent of Injury Additional Injured Parties Yes No (If yes, please include information under "Further Information or Instructions" below) Witnesses#1 Name First Name Last Name Further Information or Instructions 84674
