Automobile Claim Form

NOTE: Fields marked with * are required.

Contact Information
First Name *

Last Name *

Address (Line 1) *
Address (Line 2)
City *
County *

State *

Zip Code *

Day-Time Phone *
Evening Phone
Email Address *
How would you like us to communicate with you regarding your claim? *
When is the best time to contact you?

Accident / Loss Information
Date of Incident *
Time of Incident (Please include AM or PM) *
Location of Incident (Please include City & State)*
Authority Contacted (i.e. police, fire, etc.) *
Authority Report Number
Violation / Citations *
Description of Accident *

Were Any Witnesses Present? *

If yes, please list.

Were There Any Injuries? *
If there WERE injuries, please provide name, address, phone number and extent of the Injuries in the box.

Your Vehicle Information

Make *

Model *
Year *
Owner's Name *
Owner's Address *
If your vehicle driveable? *
If vehicle is not drivable, where was it towed?
Driver's Name (leave blank if same as owner)
Driver's Address (leave blank if same as owner)
Driver's Relation To You (i.e. employee, friend, family, etc.)
Description of Vehicle Damage *
Estimate Amount

Where Vehicle Can Be Seen (if available)? *

Other Party's Information
Other Party's Name
Address (Include City, State and Zipcode)
Contact Phone Number
Describe Property (If auto: year, make, model, plate #)
Other Vehicle / Property Insured?
Company or Agency Name
Describe Damage to Other Vehicle or Property.
Is other vehicle drivable?

Additional Comments
Please provide any additional comments on your claim here.



Copyright ©, Gem City Insurance Inc., 2003