Claims Form
NOTICE OF LOSS   AUTO   PROPERTY   LIABILITY   OTHER:
Insurance Company
 Policy Number
 Company Claim Number
Policy Effective Date
 Policy Expiry Date
Date of Loss
 Time of Loss
 Kind of Loss
Previously Reported to Company
Name of Agent/Broker
 Code(s)
 Phone

INSURED
Name:
Street Address:
City:
Province:
Email Address:
Best place to contact you with our quote
Business Home Email
Best time to contact you
Contact phone numbers:
Residential
Business   
Language Spoken
English French

COVERAGE
Type of Policy / Form Number
 Coverage
Limited / Sum Insured
 Deductibles
 Other
Lienholder / Mortgagee
    
Other Insurance
   

VEHICLE INSURED
Year, Make, Model
 V.I.N. (serial number)
 Plate No.
Owner's Name
 Owner's Address
 Owner's Phone No.
Driver's Name
 Driver's Address
 Driver's Phone No.
Relation to Insured
 Age
Driver's License No.
 Use of Vehicle
 Where can Vehicle be Seen
Used with Permission
YES NO 		Is Car Drivable
YES NO

THIRD PARTY DAMAGE
Describe Property (if auto:yr, make, model, plate no.)
 Company or Agent/Broker
Describe Damage
 Policy No.
Owner's Name
 Owner's Address
 Owner's Phone No.
Driver's Name
 Driver's Address
 Driver's Phone No.
Adjuster's Name
 Adjuster's Phone No.
 Company Claim No.

INJURED
Name
 Address
 Phone
Ins. Veh
 Other Veh.
 Age
 Extent of Injury

WITNESS
Name
 Address
 Phone
 Ins. Veh

Other Veh.

LOSS ACCIDENT
Location
Police/Fire Dept. Reported to
 Badge No
 Name
 Division
Charges Laid
Description of Loss/ Damage

 

Remarks

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