Slingluff United Insurance

Auto Claim.

Please complete the following information.

All information provided on this information sheet is confidential and will not be used for any purpose other than what it is intended.

Contact Information

First Name :
Last Name :
Contact Phone :
Email Address :
Policy Number :
Name of Insurance Company on Policy :
Vehicle Involved
Make :
Model :
Year :
Loss General :
Date of Loss :
Cause of Damage :
Estimated Damage :
The following section is applicable to Accident only :
Driver First Name :
Driver Last Name :
Relationship to Applicant :
Time of Accident :
Number of Cars Involved :
Police Notified :	Yes No
Estimated Percentage at Fault :
Location of the Accident
Street / Highway :
City / Town :
State :
Short Description :
Other Party Information (if available)
Other Driver Name :
Address :
Home Phone :
Work Phone :
Driver's License :
License Plate :
License State :
Insurance Company :
Policy Number :
Vehcile Year/Make/Model :
Damage Description :
The following section is applicable to Theft only :
Time Loss Discovered :
Date Police Notified :
Vehicle Recovered :	Yes No
Date Vehicle Recovered :
Short Description :
Online Claim Notice
I understand that any person who files a claim with the intent to defraud or helps commit a fraud against an insurer is guilty of a crime.