File A Business Auto Insurance Claim

CONTACT INFORMATION

Primary Contact

First Last

Mobile Phone

Email

Mailing Address

Street Address City State ZIP Code

Best Time To Contact

: HH

MM

INSURED INFORMATION

Is The Insured A Person Or Business?

Person
Business

Is The Primary Contact The Named Insured?

Yes
No

Name Of Insured

First Last

Name Of Business

Insured's Phone

Insured's Email

Insured's Mailing Address

Street Address City State ZIP Code

Date Of Birth

Marital Status

Married | Civil Union
Single | Divorced | Widowed

Spouse's Name

First Last

Spouse's Date Of Birth

Spouse's Phone

Spouse's Email

Federal ID Number (If Known)

INSURANCE POLICY INFORMATION

Carrier Information

Policy Number

LOSS INFORMATION

Date Of Loss

Approximate Time Of Loss

: HH

MM

Location Of Loss

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe Location Of Loss If Not At Specific Street Address

Were The Police Or Fire Department Contacted?

Yes
No

Report Number

What Kind Of Loss Is This?

Estimated Amount Of Entire Loss (If Possible)

Description Of Loss & Damage (Details)

INSURED VEHICLE

Year

Make

Model

Vehicle Identification Number

Body Type

Plate Number

Registration State

State

Vehicle Owner - Same As Named Insured?

Yes
No

Owner's Name & Address & Contact Info (Phone | Email)

Driver Is Same As First Named Insured From Above?

Yes
No

Driver's Name

First Last

Driver's Phone

Driver's Address

Street Address City State ZIP Code

Relation To Insured

Family Member
Employee

Driver's Date Of Birth

Driver's License Number

State Of License

State

Purpose Of The Vehicle's Use

Normal Daily Use
Pleasure
Business Use

Did The Driver Have Permission To Use The Vehicle?

Yes
No

Describe The Damage To The Insured Vehicle

Was A Standard Child Passenger Restraint System (Child Seat) Installed In The Vehicle At The Time Of The Accident?

Yes
No

Was The Standard Child Passenger Restraint System (Child Seat) In Use By A Child During The Time Of The Accident?

Yes
No

Did The Child Passenger Restraint System (Child Seat) Sustain A Loss At The Time Of The Accident?

First Choice
Second Choice
Third Choice

Estimated Amount Of Damage To Insured Vehicle?

Where (Location) & When Can The Insured Vehicle Be Seen?

OTHER VEHICLE | PROPERTY DAMAGED INFORMATION

Was Another Vehicle(s) | Property | Person Damaged/Injured In The Accident (Check All That Apply)

Vehicle(s)
Property
Person(s)
No Other Vehicles | Property | Persons Damaged/Injured

Other Vehicle(s) Information

Please Give Year | Make | Model of all other vehicles involved in the accident

Damaged Property Information

Describe Property That Was Damaged

Other Vehicle | Property Insured?

Yes
No
I Don't Know

Insurance Carrier

Policy Number

Property | Vehicle Owner's Information

Include Name | Address | Phone

Vehicle Driver's Information (If Different Than Owner)

Include Name | Address | Phone

Describe Damage | Injuries

Estimated Amount of Vehicle | Property Damage

Where Can The Damage Be Seen?

INJURED PARTY INFORMATION

Were Any Injuries Sustained?

Yes
No

How Many People Were Injured?

1
2
3
4+

Name Of 1st Injured Party

First Last

Address Of 1st Injured Party

Street Address City State ZIP Code

Phone Of 1st Injured Party

Where Was The 1st Injured Party

Pedestrian
Insured's Vehicle
Other Vehicle

Age Of 1st Injured Party

Description of 1st Injured Party's Injuries

Name Of 2nd Injured Party

First Last

Address Of 2nd Injured Party

Street Address City State ZIP Code

Phone Of 2nd Injured Party

Where Was The 2nd Injured Party

Pedestrian
Insured's Vehicle
Other Vehicle

Age Of 2nd Injured Party

Description of 2nd Injured Party's Injuries

Name Of 3rd Injured Party

First Last

Address Of 3rd Injured Party

Street Address City State ZIP Code

Phone Of 3rd Injured Party

Where Was The 3rd Injured Party

Pedestrian
Insured's Vehicle
Other Vehicle

Age Of 3rd Injured Party

Description of 3rd Injured Party's Injuries

Name Of 4th Injured Party

First Last

Address Of 4th Injured Party

Street Address City State ZIP Code

Phone Of 4th Injured Party

Where Was The 4th Injured Party

Pedestrian
Insured's Vehicle
Other Vehicle

Age Of 4th Injured Party

Description of 4th Injured Party's Injuries

WITNESSES OR PASSENGERS

Were The Any Passengers Or Witnesses?

Yes
No

How Many Witnesses Or Passengers?

1
2
3

Name Of 1st Witness/Passenger

First Last

Address of 1st Witness/Passenger

Street Address City State ZIP Code

Phone Of 1st Witness/Passenger

Location of 1st Witness/Passenger

Insured Vehicle
Other Vehicle
Other (Explain)

Explain Other Location Of 1st Witness/Passenger

Name Of 2nd Witness/Passenger

First Last

Address of 2nd Witness/Passenger

Street Address City State ZIP Code

Phone Of 2nd Witness/Passenger

Location of 2nd Witness/Passenger

Insured Vehicle
Other Vehicle
Other (Explain)

Explain Other Location Of 2nd Witness/Passenger

Name Of 3rd Witness/Passenger

First Last

Address of 3rd Witness/Passenger

Street Address City State ZIP Code

Phone Of 3rd Witness/Passenger

Location of 3rd Witness/Passenger

Insured Vehicle
Other Vehicle
Other (Explain)

Explain Other Location Of 3rd Witness/Passenger

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