|
COMPANY INFO. |
|
Company Name:
|
Date (MM/DD/YY):
|
Company Address:
|
Company Phone:
|
Claim Number:
|
Date of Loss (MM/DD/YY):
|
|
INSURED |
|
|
Insured's Name:
|
Insured's Residence Phone:
|
Whom to Contact:
|
Insured's Business Phone:
|
Best Time to Contact:
DayEvening |
|
LOSS |
|
Location of Accident:
|
Policy Information:
Policy Amount:
|
Description of Accident:
|
|
INSURED VEHICLE |
|
|
Vehicle Number: |
Year, Make, Model:
|
|
VIN Number: |
Plate:
|
Owner's Name:
|
Owner's Address:
|
Driver's Name:
Check if same as owner:
|
Driver's Address:
|
Drivers Phone:
|
Describe Damage:
|
|
|
|
PROPERTY DAMAGED |
Describe Property (If Auto, Year, Make,
Model, Plate Number):
|
Where can damage be seen?
|
|
INJURED |
Injured Parties Name:
|
Injured Parties Address:
|
|
WITNESSES OR PASSENGERS |
Witness Name:
|
Witness Address:
|
General Information (Services Needed to
Complete the Claim):
|
|
ADJUSTER INFORMATION |
Reported by:
|
Date Assigned (MM/DD/YY):
|
