Client/Agency Information
Co. Claim No.
Policy No.
Policy Dates From To
Renewal Yes No
Insurance Company
Insurance Company
Address 1
Address 2
City
State Zip Code
Attention
Phone Fax
E-mail
Agent and Address
Last Name or Business
First Name
Address 1
Address 2
City
State Zip Code
Phone Number
Policyholder/Contact Information
Insured #1 At Time of Loss
Last Name or Business
First Name
Address 1
Address 2
City
State Zip Code
Contact Name
Contact Phone
Home
Work/Business Ext.
Alternate
Best Time
Email
Time and Place
Date & Time of Loss or Accident
Date
Time
Location of Loss or Accident
Address 1
Address 2
City
State Zip Code
Loss Information/Type of Assignment
If the loss location is the same as Insured #1, please insert "same" in the Address 1 below.
Address 1
Address 2
City
State Zip Code
Date of Loss
Type of Assignment
Description of Loss
Claimant Information

Last Name
First Name
Address 1
Address 2
City
State Zip Code

Phone Numbers and e-mail
Home
Work/Business Ext.
Alternate
Best Time
Email
Age
Occupation
What was the Injured doing when hurt?
Employed By
Last Name or Business
First Name
Address 1
Address 2
City
State Zip Code
Phone
The Injury
Nature and Extent of Injury
Where was Injured taken after accident?
Probable disability
Return to work date
Doctor
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Phone
Property Damage
Owner
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Home Phone
Work/Business Phone Ext.
Alternate
List damage
Estimated cost of repair
Witnesses
Witness #1
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Home Phone
Work/Business Phone Ext.
Witness #2
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Home Phone
Work/Business Phone Ext.
Witness #3
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Home Phone
Work/Business Phone Ext.
Witness #4
Last Name
First Name
Address 1
Address 2
City
State Zip Code
Home Phone
Work/Business Phone Ext.
Description of Accident
Be particular to obtain the names and addressed of disinterested witnesses who know everything about the occurrence including date, badge number, or name of police authority of whom the accident was reported.
Other Insurance
Does any other insurance apply? Yes No
If yes, please identify.
Company
Address 1
Address 2
City
State Zip Code
Phone
Specific Handling Instructions