Auto Claim Notice

*Required
Insured Information
Policy Number*
Company Name
First Name*
Last Name*
Daytime Telephone Number*
Mobile Telephone Number
Fax Number
Your Email Address*
For Insurance Agents & Brokers Only: Brokers Name
Claim Details
Date of Accident or Occurrence*
Time of Accident or Occurrence*
Location of Accident*
Address or intersection*
City*
State*
Zip
Telephone Number*
Fax Number
Authority contacted & report #*
Detailed Description of Accident or Occurrence*
Injured Person(s)
Name, Address, Telephone, Ages, Sex & Occupation of all injured persons
Describe Injuries
Where was injured person(s) taken? (example: hospital, etc.)
What was injured person(s) doing when injury occurred?
Property Damaged
Describe Damage to Property
Name, Address, & Telephone of Property Owner(s)
Estimated amount of damage?
Where & when can property be seen?
Witnesses
Indicate Name, Address, and Telephone numbers for all witnesses
Acknowledgement
Name of person completing this form*
Date of completion*