YV Page • Engle Martin

Type of Claim*

Submitter's Contact Information

Name*

First Last

Phone*

Email Address

Relationship to Insured*

Who do you represent?*

Store Number

Manager's Name

Location Address*

If street address unknown, enter TBD.

Street Address Address Line 2 City State ZIP Code

Claim Information

Same contact information as "submitter" section?

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Name of Insured*

First Last

Phone Number

Insured's Email Address

Insured's Mailing Address

Street Address Address Line 2 City State ZIP Code

Insured's Policy Number

Please write in "N/A" if not applicable

Claimant's Information

Claimant's Name*

First Last

Claimant's Claim Number

Name of Insurance Company

Date of Incident*

Time of Incident

: HH

MM

Location of Incident*

If street address unknown, enter TBD.

Street Address Address Line 2 City State ZIP Code

Description of Incident*

Police or Fire Department Contacted?

Is there a police or fire report?

Police or Fire Report Number*

Injured Parties

Was there an injury involved?

Name of injured party

First Last

Injured party's date of birth

Injured party's contact number

Injured party's email address

Injured party's mailing address

Street Address Address Line 2 City State ZIP Code

Description of Injuries

Medical Treatment at the scene? (first aid, ambulance, etc.)

Witness Information

Witnesses?

Names and Contact Information

First Name	Last Name	Phone

Name of any employees who interacted with the injured party at the time of the incident or after the incident

First Name	Last Name	Phone

Was injured party dining?

Was injured party drinking alcohol?

If incident was a slip and fall, were there any foreign materials on the floor?

Was the floor wet?

Was the floor clean?

What were the lighting conditions?

Insured Information

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Insured's name*

First Last

Insured's contact number

Insured's policy number

Insured's email address

Insured's address

Street Address Address Line 2 City State ZIP Code

Accident Information

Date of accident*

Time of accident

: HH

MM

Location of accident

Location City State

Description of accident

Are there any photographs available?

Photograph Upload

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Authority contacted?

Is there a police report?

Police Report Upload

Witness(es)?

Witness information

Insured Vehicle Information

Make

Model

Year

VIN Number

Driver's name

First Last

Driver's contact number

Policy number

Driver's email address

Driver's address

Street Address Address Line 2 City State ZIP Code

Description of damages

Claimant Information

Claimant's name

First Last

Claimant type

Claimant contact number

Claimant's email address

Claimant address

Street Address Address Line 2 City State ZIP Code

Claimant's injuries

Claimant Insurance Information

Insurance Policy Number

Insurance Company Name

Claimant Property Damage Information

Owner's name

First Last

Owner's contact number

Owner's email address

Owner's address

Street Address Address Line 2 City State ZIP Code

Description of damage

Injured Party's Information

Driver/Passenger

Vehicle Number

Name

Address

City

State

Zip Code

Contact Number

Email Address

Description of Injury

Witness Information

Name

Address

City

State

Zip Code

Contact number

Email address

Any Additional Information/Comments

Details

Upload Document(s) to the Claim (Acord form, photos, policy etc.)

File(s)

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