MISC - Claim Data Collection Form

Insured Name / Policy Holders Name *

Claim Reported by: *

Primary Contact Name: *

Primary Contact Phone: *

Primary Contact Email: *

Insurance Company & Policy Number (If Known)

Type of Claim / Incident

Date of Loss * +

Date Reported * +

Approximate Time of Claim *

Description of Incident / What Happened / Please Provide as Much Detail as Possible *

Description of Damage / What Was Damaged *

Other Party's Information (If Known Please Provide Name / Phone Number / Address / Any Other Known Information):

Injuries (If Any):

Best Point of Contact (Please Provide as Much Contact Information as Possible)

Additional Notes / Comments for the Insurance Agent