Name:
Address:	Street City                                                          State          Zip
E-mail Address:
Daytime Phone:
Home Phone:
Policy Number:
Contact Person: Who should the adjuster contact about repairs?	Name: Home phone: Daytime phone: Email address:
Authority Contacted:	Police department: Report number:
Claim Information:	Date of loss: Location of claim: Cause of loss: Collision Fire Glass breakage Theft Vandalism Wind Damage Other-describe below Describe, if other cause of loss:
Your Damaged Car:	Year/Make/Model: Driver's name/address: Driver's phone number: Describe your damage: Where is the car now?
Persons Injured:	Name and address: Phone number: Nature of Injuries:
Describe Other Car:	Year/Make/Model: Owner's name/address: Owner's PH# Driver's name/address: Driver's phone number: Describe damage: Insurance company:
Describe What Occurred:
Additional Information or Comment