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(800) 937-3965

Report a Claim

Please complete this form to expedite any processing of your claims.

Date Calendar
Producer
Phone Number
Code
Agency Customer ID
Company
Miscellaneous Info
(Site and Location Code)
Policy Number
Reference Number
CAT #
Effective Date Calendar
Expiration Date Calendar
Accident Date Calendar
Accident Time
AM PM
Previously Reported
Yes No
 
Insured
Name and Address:
Social Security #
Residence Phone:
Business Phone:
 
Contact
Name and Address:
Contact Insured:
Yes No
Residence Phone:
Business Phone:
Where to contact:
When to contact:
 
Loss
Location of Accident
(Include City and State)
Authority Contacted:
Report #:
Violations/Citations:
Description of Accident:
 
Policy Information
Bodily Injury (Per Person):
Bodily Injury(Per Accident):
Property Damage:
Single Limit:
Medical Payment:
OTC Deductible:
Other Coverage & Deductibles
(UM,no-fault,towing,etc):
Loss Payee:
Collision Deductible:
Umbrella Excess:
Umbrella:
Excess:
Carrier:
Limits:
AGGR:
Per Claim:
Per OCC:
 
Insured Vehicle
VEH #:
Year:
Make:
Model:
Body Type:
V.I.N.:
Plate Number:
State:
Owner's Name & Address:
Residence Phone (A/C,Ext.):
Busines Phone (A/C,Ext.):
Driver's Name & Address
(If different from Owner)
Residence Phone (A/C,Ext.):
Busines Phone (A/C,Ext.):
Relationship to Insured
(Employeed,family, etc.)
Date of Birth: Calendar
Driver's License Number:
State:
Purpose of Use:
Used With Permission:
Yes No
Describe Damage:
Estimate Amount:
Where can the vehicle be seen?
When can the vehicle be seen?
Other insurance on vehicle:
 
Property Damaged
VEH#:
Year:
Make:
Model:
Body Type:
V.I.N.:
Plate Number:
Describe property:
Other Vehicle/Property Ins:
Yes No
Company or Agency Name:
Policy#:
Owner's Name & Address:
Residence Phone (A/C,Ext.):
Busines Phone (A/C,Ext.):
Other Driver's Name & Address
(If different from Owner)
Residence Phone (A/C,Ext.):
Busines Phone (A/C,Ext.):
Describe Damage:
Estimate Amount:
Where can damage be seen?
 
Injured # 1
Name and Address:
Phone:
Age:
Extent of Injury:
Pedestrian Insured Vehicle
Other Vehicle
 
Injured # 2
Name and Address:
Phone:
Age:
Extent of Injury:
Pedestrian Insured Vehicle
Other Vehicle
 
Witness or Passenger # 1
Name and Address:
Phone:
Other (Specify):
Insured Vehicle
Other Vehicle
 
Witness of Passenger #2
Name and Address:
Phone:
Other (Specify):
Insured Vehicle
Other Vehicle
 
Other Information
Remarks:
Reported By:
Reported To:

Applicable in California

Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties.

Applicable in Nevada

Pursuant to NRS 666A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

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©2008 CenCal Insurance Services, Inc.
CA LIC# 0791237