Claim for Damage and/or Injury To: _______________________________________ GENERAL INFORMATION 1. Claimant (a) Full name: ________________________________________ (b) Address: __________________________________________ City: _________________________ County: _____________ State: _________________ Zip Code: __________________ (c) Age: _______ (d) Marital status: _______________________ 2. If claimant is married, name and address of spouse: __________________________________________________ __________________________________________________ AMOUNT OF CLAIM 3. Amount claimed for property damage: ___________________ 4. Amount claimed for personal injury: _____________________ 5. Total amount claimed: ________________________________ ACCIDENT RESULTING IN CLAIM 6. Place of accident (include town or city and state; if outside city limits, indicate distance to nearest city or town): __________________________________________________ 7. Date and time of accident: ____________________________ __________________________________________________ (a) Day of week: ________________________________________ (b) Date: _____________________________________________ (c) Time: _____________________________________________ 8. Description of accident (a) Names and addresses of persons involved: ______________ __________________________________________________ (b) Identification of property involved: ______________________ __________________________________________________ (c) Surrounding circumstances: __________________________ __________________________________________________ (d) Cause of accident: __________________________________ __________________________________________________ (e) Other pertinent facts: ________________________________ __________________________________________________ 9. Name and addresses of witnesses to accident: ____________ __________________________________________________ PROPERTY DAMAGE AND PERSONAL INJURY 10. Property damage (a) Description of property damaged: ______________________ __________________________________________________ (b) Present location: ____________________________________ (c) Name and address of owner, if other than claimant: ________ __________________________________________________ (d) Nature of damage: ___________________________________ (e) Extent of damage: ___________________________________ 11. Personal injury (a) Nature of injury: ____________________________________ _________________________________________________ (b) Extent of injury: ____________________________________ _________________________________________________ INSURANCE COVERAGE 12. Collision insurance (a) Does claimant carry collision insurance? (If yes, answer (b)- (f) below) ______________________ (b) Name and address of insurer: _________________________ __________________________________________________ (c) Policy No.: _________________________________________ (d) Has claimant filed claim against insurer in this instance? _________________________________________________ (e) If claim has been filed, is coverage for full amount of loss? _________________________________________________ If not full coverage, amount deductible: ________________ ________________________________________________ (f) If claim has been filed, action taken or proposed to be taken by insurer with respect to claim: _________________________________________________________ 13. Public liability and property damage insurance (a) Does claimant carry public liability and property damage coverage? (If yes, answer (b) below) _______ (b) Name of insurer: ____________________________________ I declare under the penalty of perjury that the amount of this claim covers only damages and injuries caused by the accident described above. I agree to accept that amount in full satisfaction and final settlement of this claim. Dated: __________________________ _______________________________________________ Signature Claim for Damage and/or Injury Review List This review list is provided to inform you about this document in question and assist you in its preparation. Use this document to transmit your claim to your insurance agency. Be complete; add any necessary and useful exhibits. The more thorough you are the more apt you are to be believed and get prompt payment. 1. Make multiple copies. Give one set to the insurance agency. Keep a backup set (agencies are notorious for losing or misplacing paperwork). Keep one set with the transaction file. 2. Remember that getting paid on a claim is a sales situation. If they are “sold” on your credibility, they will generally pay promptly. If not sold, it can be a long and ugly process. As we have said before, you have one chance to make a good first impression. Do your homework; get a complete and thorough file together; send it to them promptly. All of this will increase the odds of a satisfactory result in your favor.