Claim Reporting Form
Page Insurance, Ltd
102 Boston Street
Guilford, CT 06437
(203) 453-5258
info@pageins.com
Today's Date
-
Month
-
Day
Year
Date Picker Icon
Date of Loss or Accident
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Month
-
Day
Year
Date Picker Icon
Name of Insured
First Name
Last Name
Company Name (if applicable)
Contact Name
First Name
Last Name
Contact Phone Number
Format: (000) 000-0000.
Contact Cell Phone
Format: (000) 000-0000.
Contact Email Address
Insurance Company
Policy Number
Policy Effective Date
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Month
-
Day
Year
Date Picker Icon
Was the police / fire department notified?
Yes
No
Town/City of Police Department
Police Department Case Number
Type of Policy:
Please select
Automobile
Business
Farmowners
Homeowners
Liability
Type of Loss:
Auto Accident
Auto Glass Only
Business Income
Fire
Liability
Mysterious Disappearance
Smoke
Theft
Tree(s)
Water Damage
Wind
Other
Location of Loss
Insured Location
Description of accident or claim
Personal Auto Policy Claims
For our insured, we need the following:
Were there any injuries?
Yes
No
Extent of Injuries
Names of Injured Parties (if any)
Vehicle Year
Vehicle Make
Vehicle Model
VIN
Who was driving?
Where is the vehicle located?
Was there damage to others' property?
Yes
No
Description of Property Damage
For the other party, we need the following:
Name
First Name
Last Name
Insurance Carrier
Policy Number
Vehicle Year
Vehicle Make
Vehicle Model
Emergency Repairs Needed?
Yes
No
What repairs are needed?
Who was driving?
Were there any passengers?
Yes
No
Names of Passengers
Were there any witnesses?
Yes
No
N/A
Names of witnesses
Reported By
Notes
File Attachments
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