Iron Range Agency_01-0967-00

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Iron Range Agency
* PLEASE NOTE IF YOU ARE COMPLETING THIS FORM AFTER HOURS *

BY COMPLETING THIS FORM YOUR LOSS WILL BE GIVEN IMMEDIATE ATTENTION WHEN OUR OFFICE HOURS RESUME.
Date of Occurrence

MonthDayYear
Date
Your Name

First NameLast Name
What is the best number to reach you?

Area CodePhone Number
Email Address
example@example.com
Auto
Brief description of incident:
Who was driving?
Which Vehicle?
Was anyone injured?

YesNo
If so, who?
Taken to hospital?

YesNo
If so, which hospital?
Where did the incident occur?
Were the police called?

YesNo
If so, which department?
Is the vehicle drive-able?

YesNo
If not, where can vehicle be seen?
Home
Brief description of incident:
What has been damaged?
Have you called a cleaning or restoration company?

YesNo
If so, who?
If not, do you need one?
* Please Note * It is the homeowners responsiblity to make temporary repairs to prevent any additional damages from occuring until an insurance adjuster can look at the damage. This could mean cleaning up water, putting a tarp over, or boarding up holes.
Verification Code: Enter the message as it's shown*
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