Automobile

Tools & Resources

Auto Claim Report

In an emergency claim situation, please contact our office directly.

Please take your time filling out this form. You will be given an opportunity to check for errors.

Note that items marked with an asterisk are required.


Policy Holder Information

 

Policy Number:*

Primary Contact Person:*

Home Phone:*

Work Phone:

Where should we contact you?    

 

Best time to contact you?    

 

Accident Information

 

Who was driving?

Date of Loss or Accident:

Time of Accident:

Vehicle Year:

Vehicle Make:

Vehicle Model:

Is the vehicle drivable?

 

If no, where can the vehicle be inspected?

 

Please provide as much detail as possible regarding the claim in the spece provided below. A reporesentative will contact you shortly.

 

Did any injuries result from the Accident?

 

If yes, please provide names, addresses, phone numbers and the extent of the injuries.

 

Other Driver Information

 

Full Name:

Insurance Provider:

Policy Number:

Contact Phone:*

Licence Plate #:

Vehicle Year:

Vehicle Make:

Vehicle Model:

 

Location of Accident

 

City / Province:

Police Contacted?*

Officer's Name:

Officer's Badge Number:

Report Number:

 

Were there witnesses?*

 

Witness #1

 

First Name:

Last Name:

Contact Phone:

Work Phone:

Email Address:

Name of your broker: