Insurance Claim Automobile - INSURANCE CLAIM WORKSHEET

							INSURANCE CLAIM WORKSHEET
AUTOMOBILE ACCIDENT

PRODUCTION
DA TE OF OCCURRE NCE                                      TIME
LOCA TION OF OCCURRENCE




HOW DID A CCIDE NT OCCUR




INS URED VEHICLE (Year, Make, Model)
VEHICLE ID #                                              LIC. PLA TE #
 OWNER OF VEHICLE
          ADDRESS


           PHONE #                                        CONTACT
               DRIVER
          POSITION
     DRIVER’S LIC. #                                                       USED W/PERMISS ION            YES
                                                                                                    NO
          ADDRESS


           PHONE #
 WHERE CA N CAR BE SEEN
                        WHEN
DAMAGE TO CA R


ESTIMA TE(S) TO REPAIR $
DAMAGE TO OTHER VE HICLE (Y ear, Make, Model)

                                                          LIC. PLA TE #
DRIVER OF OTHE R VEHICLE
                   ADDRESS


                  PHONE(S) #
WHERE CA N CAR BE SEEN
                        WHEN
DAMAGE TO CA R


ESTIMA TE(S) TO REPAIR $



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                        INSURANCE CLAIM WORKSHEET—page 2
INJURE D
ADDRESS
PHONE #
E XTENT OF INJURY




WITNESS(ES)
   ADDRESS


    PHONE #

   POLICE REPORT A TTACHE D

   OTHER
ATTA CHME NTS


SUBMITTE D TO INS URANCE AGENCY ON
ATTE NTION
CLA IM #
INS URANCE COMPA NY CLA IMS REP.
INS URANCE CLA IM WORKS HEE T COMPLE TED BY
DA TE                      TITLE
INS URANCE ADJUS TE R TO SEE INS URED VEHICLE ON
                       TO SEE OTHER VEHICLE ON
AMOUNT CREDITE D TO DE DUCTIBLE $                  DA TE
REIMB URSEMENT CHE CK PAID TO
                     AMOUNT $                      DA TE
                              TO
                     AMOUNT $                      DA TE
NOTES: