Claims

REPORT CLAIMS

Please provide as much information as possible to ensure the best communication.

Items marked with * are required

 

REPORTED BY: *  
Company:  
Contact Name: *  
Telephone: *  
Email: *  

REPORTED TO BRANCH: *  

INSURER
Contact Name: *
(last, first)		  
Company: *  
Address:  
City: *  
Prov / State:  
Country:  
Postal/ZIP Code:  
Telephone:  
Fax:  
Email:  
Subscription
Information:		  

   

If YES, list % and the names of all subscribers and their %:  

 

INSURED
Contact Name: *
(last, first)		  
Company:  
Address:
  
City: *  
Prov / State:  
Country:  
Postal/ZIP Code:  
Residence Telephone: *  
Business Telephone:  
Cell Phone:  
Fax:  
Email:  

 

BROKER - provide info if available
Contact Name:
(last, first)		  
Company:  
Address:
 		  
City:  
Prov / State:  
Country:  
Postal/ZIP Code:  
Telephone:  
Fax:  
Email:  

LOSS INFORMATION

Policy Number:  
Claim Number:  
Policy Expiry Date:  
Date of Loss *
(yyyy/mm/dd):		  
Policy Coverage:
Type of Loss: *
Note: CMD-click to select multiple types		  
Insured Item:  
Location of Loss:  
Circumstances of Loss:  

AUTO CLAIM

Plate Number:  
Plate Province / State:  
Make / Model / Colour:  
Year:  
VIN (Serial) Number:  
Is the car drivable?  

   

Location of Loss:  
Driver Name:
(last, first)		  
Driver Address:  
Driver Res. Phone:  
Driver Bus. Phone:  
Driver Cell Phone:  

THIRD PARTY CLAIMANTS

Claimant #1
Claimant Name:
(last, first)		  
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #2
Claimant Name:
(last, first)		  
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #3
Claimant Name:
(last, first)		  
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #4
Claimant Name:
(last, first)		  
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Specific Handling Instructions:  
   
   

Service Locations

Doing What is Right®

 

 

 

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