Paul & Dixon Insurance Agency - Report an Automobile Claim

PRELIMINARY REPORT OF AUTO CLAIM

Name of Insured

First

Last

Address of Insured

Address

City

State

Zip Code

Preferred Phone

Alternate Phone

Email Address

Claim Information

Policy Number (if available)

Date of Accident/Loss

Approx. Location of Accident/Loss

Were Police Notified?

Yes

No

Cause of Loss

Describe if Other Cause

Any Injuries?

Yes

No

Vehicle Information

Insured (Year, Make, Model)

Insured Vehicle Reg. Number

Name of Insured Vehicle Driver

Driver of Insured Vehicle Lic. #

Other (Year, Make, Model)

Other Vehicle Reg. Number

Driver #2 name

Driver #2 License Number

Describe Circumstances

Describe Damage

Witnesses (name & phone)

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