Client Contact Information
*	First Name:
*	Last Name:
	Address:
*	Email Address:
*	Telephone:
	Fax:
	Claim Information
*	Date Requested:
*	Insurance Company:
*	Claim Number:
	Policy Number:
	Insured Name:
	Insured Number:
	Insured Address:
	Claimant Name:
	Claimant Number:
	Claimant Address:
	Loss Information
*	Date of Loss / Occurrence:
*	Loss Location:
*	Type of Loss:
*	Description of Loss:
	Statement Information
	Recorded Statement:	Select In Person Telephone
	Name:
	Address:
	Home Phone:
	Work Phone:
	Signed Statement:	Select Insured  Claimant  Witness
	Name:
	Address:
	Home Phone:
	Work Phone:
	Police Report
	City or Township:
	Street(s), Highway:
	Driver’s Name:
	Report Number:
	Accident Location:
	Special Instruction: (Please send Police Report if available)
	Attachment: Upload any attachment(pdf/office/image format)