YV Page • Engle Martin

Type of Claim
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 insured?
- Copy contact information
Name of Insured*
First Last
Insured's Mailing Address
Street Address Address Line 2 City State ZIP Code
Insured's Contact Number
Insured's Policy Number
Insured's Email Address
Claimant's Name
First Last
Claimant's Claim Number
Name of Insurance Company
Date of Incident*
Date Format: MM slash DD slash YYYY
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*
Claimant / Witness Information
Name of injured party
First Last
Injured party's date of birth
Date Format: MM slash DD slash YYYY
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.)
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
Copy contact information as insured?
- Copy
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*
Date Format: MM slash DD slash YYYY
Time of accident

: HH

MM
Location of accident
Location City State
Description of accident
Are there any photographs available?
Photograph Upload
Drop files here or
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)
Drop files here or

First Name	Last Name	Phone

First Name	Last Name	Phone

Contact Information

Claim Information

Claimant / Witness Information

Insured Information

Accident Information

Insured Vehicle Information

Claimant Information

Claimant Insurance Information

Claimant Property Damage Information

Injured Party's Information

Witness Information

Any Additional Information/Comments

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