RWR Auto Claim Report Form
Company Information
Company Name*
Location
Policy Number
Reported By*
Reported By Phone No*
Reported By Email
Vehicle Information
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle Plate Number
Vehicle Plate State
Vehicle V.I.N.
Vehicle Type
Driver Information
Driver's Name*
Confirm Driver's Name*
Driver's Address*
Driver's Phone*
Driver's Email
Driver's License State
Driver's Date of Hire (mm/dd/yyyy)
Driver's Date of Birth* (mm/dd/yyyy)
Driver's Gender*
Time Driver Began Work
Loss Information
Date of Accident* (mm/dd/yyyy)
Time of Accident
Description of Injury/Damages*
Accident Type*
Roadway Type
Roadway Condition
Light Condition
Contributing Conditions*
Driver Action
Liability Status
Preventability
Police or Fire Dept Contacted?
Police or Fire Station Responding
Witness Information
Witness Name
Witness Phone Number
Witness Email
Witness Address
Witness City
Witness State
Witness Zip
Third Party Information
Third Party Name
Third Party Phone Number
Third Party Address
Third Party Description of Injury/Damages
Any other third parties involved?
Attachment(File)
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