Auto Claim Report
General
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Date of Loss:
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Policy Number:
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Time of Loss:
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:
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AM
PM
HH
MM
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Reported by:
Agent Name:
Agent Tel:
-
-
XXX
XXX
XXXX
Insured Details
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Insured Name:
Street Addr:
City:
State:
Zip Code:
Resident Tel:
-
-
XXX
XXX
XXXX
Business Tel:
-
-
XXX
XXX
XXXX
Mobile:
-
-
XXX
XXX
XXXX
E-mail:
Was insured the driver?
YES
NO
Was insured injured?
YES
NO
Type of Injury:
Loss Information
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Description of Incident:
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Location of Incident
Street Addr:
City:
State:
Were the Police Called?
YES
NO
Name of Police Department Investigating:
Any Tickets Issued?
YES
NO
To Whom?
Claimant Details
Name:
Street Addr:
City:
State:
Zip Code:
Resident Tel:
-
-
XXX
XXX
XXXX
Business Tel:
-
-
XXX
XXX
XXXX
Mobile:
-
-
XXX
XXX
XXXX
E-mail:
Injured?
YES
NO
Type of Injury:
Add another Claimant details
Witness
Witness Name:
Street Addr:
City:
State:
Zip Code:
Phone:
-
-
XXX
XXX
XXXX
E-mail:
Add another Witness details
Other Property Damage
Name:
Street Addr:
City:
State:
Zip Code:
Phone:
-
-
XXX
XXX
XXXX
E-mail:
Damaged Property:
Location of Property:
Add more...
Other Information
Other Information:
By submitting this claim, I certify that the facts as stated herein are true to the best of my knowledge, information and believe. I acknowledge that it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of committing fraud. I understand that this claim form does not alter my insurance policy and that my claim will be evaluated based on the coverage provided by my insurance policy, including any exclusions and limitations contained therein.
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Policyholder Signature:
Please enter the code shown below:
I have read and agree to
the
Website Terms of Use
and the
State Specific Fraud Warnings