subject_line
Auto Claim Reporting
Claim Reported by:
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Primary Point of Contact:
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Primary Point of Contact Phone:
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Primary Point of Contact Email:
*
Date of Incident
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Time of Accident
Location of Accident
Policy Holders Name
*
Policy Number if Known
Driver at the time of the Incident
Name
Drivers License #
Other
Phone
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Vehicle Info
Year / Make / Model
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Description of Damage (Is the vehicle driveable?)
If not driveable, where is the vehicle now?
Other Party's Info (If Known)
Name
Drivers License #
Phone Number
Vehicle Type
Insurance Information
Other Info
Injuries if any?
Passengers if any?
Responding Police Department / Policy Report Number (If Applicable)
Description of Incident (What happened?)