Casualty Claim

    Date:

    Name:

    E-Mail:

    Company:

    Company
    Address:

    State:

 

ZIP/Postal Code:

    Phone:

Fax:

    Policy # :

Claim #:

    Effective
    Dates:

 


TO

    Date of
    Loss: 

    Time of
    Loss:

  

A.M.

P.M.

                    ___________________________________________________

Insured

    Name:

    Address:

    State:

ZIP Code:

    Phone:

Work #:

    Person to
    Contact:

    Contacts
    Phone:

_________________________________________________

Facts

    Loss
    Location:



    Description of Loss:

    ___________________________________________

Policy Information

    Bodily
    Injury:



    Property
    Damage:



       

    Combined
    Single Limit:



Medical
Payments:



    Comprehensive
    Deductible:



   Collision
   Deductible:



    Other Deductibles:


    Loss Payee:


______________________________________________

Insured Vehicle

    Vehicle #


Year:


    Make:


Model:


    Plate #


VIN #


    Owners Name:


    Owners Address:


    State:


ZIP Code:


    Owners Phone:

   
    Driver's Name:
   
    Driver's Address:
    State:


ZIP Code:
    Driver's Phone:

    Relation to Insured:
    Driver's License #
    Date of Birth:
    Describe Damage:
    Repair Estimate:
    Damaged Vehicle  
    Location:

Property Damage

    Description:

    Other Party Insured?:

YES    NO
    Company/Agency:
    Name:
    Policy #
    Owner:
    Owner's Address:
    State: ZIP Code:
    Driver's Phone:
    Describe Damage:
    Estimate Amount:
    Location of Vehicle:
    More Than One  
    Adverse Vehicle:

YES     NO

Witnesses

    #1 Name:

    Address:
    State: ZIP Code:
    Phone: Age:
     
    #2 Name:
    Address:
    State: Zip Code:
    Phone: Age:

Further Information or Instructions