FILE A CLAIM Insured Name   Policy#   Address   City   State  ZIP     Phone    Home Work Cell Pager   Email Driver of Insured Vehicle Make Model of Insured Vehicle Date of Loss Time a.m. p.m. Description of Accident / Loss Name of Other Party (claimant): Address   City   State  ZIP     Phone    Home Work Cell Pager Make Model of Claimant Vehicle   Names of Other Occupants of Either Vehicle: Name Vehicle Occupied Insured Claimant Injured yes no Name Vehicle Occupied Insured Claimant Injured yes no   Name Vehicle Occupied Insured Claimant Injured yes no   Name Vehicle Occupied Insured Claimant Injured yes no   Name Transported by Ambulance? yes no Where? Were Police Called? yes no Which Police Department? Were Citations Issued? yes no Who Received Citations? Insured Claimant Is Insured Car Driveable? yes no Where is Car Located Now? Is Claimant Car Driveable? yes no Where is Car Located Now?     Home ] Free Quote ] Agent Finder ] Safety First ] Employment ] About us ] © ; AffiliatedSpartan Insurance Agencies, Inc. , 1997-2002