Claim form

Name of insured:
Policy number:
Address:
Phone:
Business phone:
Date loss occurred:
Time of loss:
Address where loss occurred:
Type of claim:
Were the police notified: Yes
No
Police report number:
Anyone injured: Yes
No
If yes, was first aid given? Yes
No
Name of hospital:
Attending physician:
Address:
Phone:
Description of injury or accident:
Property damaged (Give model #, serial #, estimated value, and description of damage for each item:
Additional comments: