General Claim Details
Today's Date
*
/
Month
/
Day
Year
Claim Reported By
*
Phone Number
*
Phone Type
*
Cellular
Home
Work
Relationship to insured
*
Foe example: Self , Husband, Wife
Policy Type
*
For example: Motorcycle, ATV, Snowmobile
Policy Number
*
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Date of Loss (or Discovery Date)
*
/
Month
/
Day
Year
Date
Insured Name
First Name
Last Name
Insured Address (Please verify the address is current)
*
Preferred Contact Phone Number
*
Phone Type
*
Cell
Home
Work
Email Address
*
example@example.com
May we use your email address to send claim correspondence?
*
Yes
No
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Loss Location (Street or Intersection and City and State)
*
Unit/Property Involved: (Year, Make, Model or Property Address)
*
For Example: 2009 Harley Davidson Street Glide
Describe What Happened (Please get as many details as possible)
*
VIN/HIN
Please add vehicle identification number
Where is the unit is located at this time
If the bike is at a tow yard, “please have the bike moved either to a shop or your home as soon as possible.” DO NOT tell them an adjuster will come out
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Police/Fire/Authority Information
NA
Organization name
Report Number
Officer Name
Phone
Injured Party Information (If more than 2, add information in "Additional Comments")
NA
Name
Address
Phone
Name
Address
Phone
3rd Party Information
NA
Name
Address
Insurance Company
Phone
Policy Number
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Witness Information
NA
Name
Address
Phone
Additional Comments
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