Auto Claims

Policy Holder Information

Policy Number

Work Phone

Primary Contact Person

Home Phone

Email

Accident Information

Who was driving?

Date of Loss or Accident

Time of Accident

Vehicle Year (YYYY)

Vehicle Model

Vehicle Make

Is the vehicle drivable?

Yes

No

If no, where can the vehicle be inspected?

Please provide as much detail as possible regarding the claim in the space provided below. A representative will contact you shortly. (Max 500 characters)

Did any injuries result from the accident?

Yes

No

If yes, please provide names, addresses, phone numbers and the extent of the injuries. (Max 500 characters)

Other Driver Information

Full Name

Insurance Provider

Contact Phone

Policy Number

Licence Plate #

Vehicle Make

Vehicle Model

Vehicle Year (YYYY)

Location of Accident

City/Province

Officer's Name

Report Number

Police Contacted?

Yes

No

Officer's Badge Number

Were there witnesses?

Yes

No

Witness #1

First Name

Contact Phone

Email

Last Name

Work Phone

Name of your Broker

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