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CLAIM REPORT FORM


	Claim Form


	How did you hear about us:

	Your insurance agent's name and phone number:
	Is there a police report?

	Section 1
	Insured title:
	Insured First Name:
	Insured Last Name:
	Street Address:
	City:	State: Zip:

	Phone Numbers; please include area code and extensions:
	Main number:
	Alternate number:
	Fax number:
	e-mail:	* (Required)

	Vehicle driver's name and address:

	The Year, Make and Model of your vehicle:
	Color:
	Plate#:
	Serial #:
	Damaged Area:

	SECTION 2:
	The other vehicles involved: (re-submit this form for each additional vehicle involved)

	Title:
	First Name:
	Last Name:
	Street Address:
	City:	State: Zip:

	Phone Numbers; please include area code and extensions:
	Main number:
	Alternate number:
	Fax number:
	e-mail:

	Other person's vehicle information
	The Year, Make and Model of other Vehicle:
	Color:
	Plate#
	Serial#
	Other person's insurance company and policy number:
	The location of the loss, address, town and state:
	The date and time the loss occurred:
	Were there any injuries?
	Accident description:
	List all witnesses (include names and phone numbers):
	Additional comments:

	Attach police report here: