Auto Claim

Auto Claim Report

CALL POLICE AND FILL OUT THE FOLLOWING

* Denotes a mandatory fields (n/a if not available)

1. Policy Details

* Insurance Company

* Policy Number

* Claim Number

* Name of Agent/Broker

Home Phone

Home Fax

Policy Effective Date

Open the calendar popup.

Claim Date

Open the calendar popup.

Claim Time

Open the time view popup.

2. Insured Details

* Last Name

* First Name

* Home Phone * Other Phone

* Address

* City

* Province

* Postal / Zip

3. Police Information Details

Investigating Officer (Full Name)

Police Force

Station/Division

Badge No

Were You Charged by Police?

select

Was The Other Driver Charged by Police?

select

Description of Damage/Accident (physical conditions)

4. Driver Information

* Owner of Other Vehicle

* Driver's License No

Home Phone Other Phone

* Address

* City

* Province

* Postal / Zip

* Other Vehicle - Model, Year, Make

* Other Vehicle Colour

* Insurance Company

* Policy Number

Accident Date

Open the calendar popup.

Accident Time

Open the time view popup.

* Accident Location: (street, intersection or highway)

* Accident City

* Accident Province/State

5. Witness Detail

IF THE WITNESS IS A MOTORIST AND YOU ARE UNABLE TO OBTAIN THEIR NAME AND ADDRESS, RECORD THEIR VEHICLE LICENSE PLATE NO.

Witness Licence Plate

Last Name

First Name

Home Phone Other Phone

Address

City

Province

Postal / Zip

Witness Was:

select

All losses should be reported directly to: Joel Carey of Partners Indemnity Brokers.

Business No.: (905) 336-1302
Mobile No.: (905) 876-6411
Facsimile: (905) 681-1054
E-mail: jcarey@csrm.ca

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Auto Claim Report

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