| INSURANCE COMPANY ADDRESS
ADJUSTERPHONEFAX
E-MAILCLAIM NUMBER
INSURED |
| Name |
Address |
|
|
|
| City & State |
Zip Code |
Email Address |
|
|
|
|
| H. Phone w/Area Code |
W. Phone w/Area Code, ext |
|
|
|
|
|
|
| Person To Contact |
Where To Contact |
When? |
|
|
|
|
|
|
|
|
|
|
|
| Policy Information |
| Bodily Injury |
Property Damage |
Single Limit |
OTC Ded. |
|
|
|
|
| Other Coverage & Deductables (UM, no-fault, towing, etc. |
Loss Payee |
|
|
| Collision Deductable |
|
|
|
|
|
|
|
| Insured Vehicle |
| Year, Make, Model |
Vehicle Identification Number |
|
|
| License Plate # |
|
Owners Name |
|
|
|
|
| Owners Address |
|
Owners Phone w/area code |
|
|
|
|
|
|
|
|
|
|
| ) |
|
|
|
|
|
|
|
|
|
|
|
|
|
Describe Damage
|
| Estimate Amount $ |
Where Can Vehicle Be Seen? |
When? |
|
|
|
| Other Insurance On Vehicle? |
|
|
|
|
|
| Property Damage |
| Describe Property (If auto - year, make, model, plate No.) |
Other Vehicle / Property Insurance? |
Company or Agency Name & Policy # |
|
|
|
| Owners Name |
Owners Address |
|
|
|
| Bus. Phone w/area code, ext. |
Res. Phone w/area code |
|
|
|
|
| Describe Damage |
|
|
|
|
| Estimate Amount $ |
Where Can Damage Be Seen? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Reported By: |
|
Reported To: |
|
|
|
|
|
|
|
|
|
|
|