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:*

Company Name:

Primary Contact Person:*

Main Phone:*

Work Phone:


Where should we contact you?    


Best time to contact you?    


Claim / Loss Information


Date of Loss or Accident:


City / Province:

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


Police Contacted?*


Officer's Name:

Officer's Badge Number:

Report Number:

Did any injuries result from the Loss / Accident:


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


Name of your broker: