Claim Report Form

Please complete the form below.

Member Name or Number

Contact Name

Contact Phone

Contact Email

Date of Loss

Time of Loss

Location

Loss Description

Follow Up Action Taken

Name and phone number of employee with the most knowledge of the incident

Was the incident investigated by authorities?

No Yes

Vehicle Description

VIN

Driver

Driver Phone Number

Property Description

Property Location

Claimant Name

Claimant Phone

Claimant Email

Claimant Loss Description

Has claimant been provided a claim for damage form?

No Yes

Property Damage

No Yes

Injury

No Yes

Upload relevant files here. (png, pdf, jpg, jpeg, docx, xlsx only)

Please complete only those fields that are applicable to your incident. Our claims team will follow up with you for more detailed information.

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