Auto Claim Form



East-Coast---Color
Auto Claim Report Form

Company*
Reported By*
Reported By Phone No*
Reported By Email

Vehicle Make*
Vehicle Model*
Vehicle Plate Number
Vehicle Plate State
Vehicle V.I.N.
Vehicle Type

Driver’s Name*
Confirm Drivers 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
Date of Accident* (mm/dd/yyyy)
Time of Accident
Description of Injury/Damages*
Roadway Type
Roadway Condition
Light Condition
Police or Fire Dept Contacted?
Police or Fire Station Responding

Witness Name
Witness Phone Number
Witness Email
Witness Address
Witness City
Witness State
Witness Zip

Third Party Name
Third Party Phone Number
Third Party Address
Third Party Description of Injury/Damages
Any other third parties involved?