Auto/Home Insurance Claim Form

Insurance Claim Form
Claimant information-person filing the claim
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation
Date & Time of Incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Incident/IF HOME CLAIM Enter details of what happened
Police Report Filed

YesNo
Police Report Number
Vehicle Information
Make and Model
Year of Manufacture
Vehicle Identification Number (VIN)
License Plate Number
Current Mileage
Briefly describe the circumstances surrounding the incident, including the events leading up to it.
Is your vehicle driveable

YESNOI don't know
Need a RENTAL CAR (if policy has rental car endorsement)

YESNO
DO you have a preferred body shop or wish us to recommend a shop? List preference.
Parties Involved-IF you have copies of ins. cards or their drivers lic. upload please.
Injuries and Medical Treatment
Description of Injuries (if any)
Medical Facilities Visited
Expenses Incurred for Medical Treatment $
Damage Assessment
Description of Damage to Your Vehicle
Description of Damage to Other Vehicle(s)
Estimated Cost of Repairs $
Attach photos of the accident scene, damages, and any relevant documents.

Cancelof
Additional Information
Declaration:

I declare that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may result in the denial of my claim.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Insurance Claim Form

Claimant information-person filing the claim

Vehicle Information

Injuries and Medical Treatment

Damage Assessment