Date:
Name:*
Email:*
Company:*
Company Address:
City: *
State / Province:
ZIP Code:
Phone: *
Fax: 
Policy #:
Effective dates
  To 
Claim #:
Date of Loss
Time of Loss:
Insured
Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:
Facts
Location of Loss:
Description of Loss or Accident:
Policy Information
Bodily 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 #:
Owner's Name:
Owner's Address:
State:
ZIP Code:
Owner's Phone:
Driver's Name:
Driver's Address:
State:
ZIP Code:
Driver's Phone:
Relation to Insured:
Driver's License #:
Date of Birth (mm/dd/yy)
Describe Damage:
Repair Estimate:
Where can vehicle be seen?
When:
Claimant Property Damage
Description:
Other Vehicle or Property Insured?
Company or Agency Name:
Policy #:
Owner/Claimant:
Owner's Address:
State:
Driver's Name:
Driver is same as Owner
Driver's Phone:
Describe Damage:
Estimate Amount:
Where can vehicle be seen:
More than one adverse vehicle?
(If yes, please include information under "Further Information or Instructions" below)
Injured Parties (Insured or Claimant)
#1 Name:
Address:
State:
Zip Code:
Phone:
Age:
Injured Party:
Extent of Injury:
#2 Name:
Address:
State:
Zip Code:
Phone:
Age:
Injured Party #2:
Extent of Injury
Additional Injured Parties?
(If yes, please include information under "Further Information or Instructions" below)
Witnesses

#1 Name:

Further Information or Instructions:

 
 
 
Sam Hooper and Associates 2016