Claims Form


Note: If you would prefer to fax or email a claims form yourself, feel free to download a copy.

Loss Type: Vehicle Collision
Pedestrian-Vehicle Collision
Slip/Trip/Fall

Your Name:
Your Company:
Your Telephone:
Your Fax:
Your Email:
 
Your Claim No.:
Insured's Name:
 
Insured's Vehicle Make/Model/Colour:
Vin/Stock No.:
Insured's Vehicle Location/Contact Number:
Engineer's Inspection Requested: Yes No
 
Other Vehicle Make/Model/Colour:
Vin/Stock No.:
Other Vehicle Location/Contact Number:
Engineer's Inspection Requested: Yes No
 
Loss Location:
Engineer's Inspection Requested: Yes No
 
Loss Date:
Loss Time:
Police Accident Report Sent: Yes No
Police Contact:
Other Contact:
Special Instructions For Engineer: