Rideshare Insurance 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 Number
*
Date of Loss (or Discovery Date)
*
/
Month
/
Day
Year
Date
Estimated Hour of Loss
*
Hour Minutes
AM
PM
AM/PM Option
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)
*
Insured Unit/Property Involved: (Year, Make, Model or Property Address)
*
For Example: 2009 Honda Accord
Was a dash cam active during the event?
*
Yes
No
Unknown
When did the incident happen?
*
During a ride with a passenger
While driving to pick up a passenger
App was on, but not on an active ride
Not during any rideshare activity
Unknown
If your answer was related to a rideshare activity, which platform (e.g.: Uber / Lyft) were you using at the time of the incident?
Describe What Happened. Include specifics such as actions taken, people involved, and any contributing factors.
*
VIN
Please add vehicle identification number
Where is the car located at this time
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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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