Automobile Accident Insurance Claim
Policyholder Name
Policy Number
Contact Number
Email Address
Date of Accident
Time of Accident
Location of Accident
Description of Accident
Vehicle Make and Model
Vehicle Year
Vehicle Registration Number
Was anyone injured?
No
Yes
Description of Injuries (if any)
Police Report Filed?
No
Yes
Police Report Number
Other Party Involved?
No
Yes
Other Party Details
Additional Comments