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Claim for Damage and/or Injury

To:  _______________________________________
GENERAL INFORMATION

1.    Claimant

(a)    Full name: ________________________________________

(b)    Address: __________________________________________

City: _________________________ County: _____________
State: _________________ Zip Code: __________________

(c)    Age: _______  (d) Marital status: _______________________

2.    If claimant is married, name and address of spouse:

__________________________________________________

__________________________________________________

AMOUNT OF CLAIM

3.    Amount claimed for property damage: ___________________

4.    Amount claimed for personal injury: _____________________

5.    Total amount claimed: ________________________________

ACCIDENT RESULTING IN CLAIM

6.    Place of accident (include town or city and state; if outside city limits, indicate distance to nearest city or town):

__________________________________________________

7.    Date and time of accident: ____________________________

__________________________________________________

(a)    Day of week: ________________________________________

(b)    Date: _____________________________________________

(c)    Time: _____________________________________________

8.    Description of accident

(a)    Names and addresses of persons involved: ______________

__________________________________________________

(b)    Identification of property involved: ______________________

__________________________________________________

(c)    Surrounding circumstances: __________________________

__________________________________________________

(d)    Cause of accident: __________________________________

__________________________________________________

(e)    Other pertinent facts: ________________________________

__________________________________________________

9.    Name and addresses of witnesses to accident: ____________

__________________________________________________

PROPERTY DAMAGE AND PERSONAL INJURY

10.    Property damage

(a)    Description of property damaged: ______________________

__________________________________________________

(b)    Present location: ____________________________________

(c)    Name and address of owner, if other than claimant: ________

__________________________________________________

(d)    Nature of damage: ___________________________________

(e)    Extent of damage: ___________________________________

11.    Personal injury

(a)    Nature of injury: ____________________________________

_________________________________________________

(b)    Extent of injury: ____________________________________

_________________________________________________

INSURANCE COVERAGE
12.    Collision insurance

(a)    Does claimant carry collision insurance? (If yes, answer (b)- (f) below)

______________________

(b)    Name and address of insurer: _________________________

__________________________________________________

(c)    Policy No.: _________________________________________

(d)    Has claimant filed claim against insurer in this instance?

_________________________________________________

(e)    If claim has been filed, is coverage for full amount of loss?

_________________________________________________

If not full coverage, amount deductible: ________________

________________________________________________

(f)    If claim has been filed, action taken or proposed to be taken by insurer with respect to claim:

_________________________________________________________

13.    Public liability and property damage insurance

(a)    Does claimant carry public liability and property damage coverage? (If yes, answer (b) below)

_______

(b)    Name of insurer: ____________________________________

I declare under the penalty of perjury that the amount of this claim covers only damages and injuries caused by the accident described above. I agree to accept that amount in full satisfaction and final settlement of this claim.

Dated: __________________________

_______________________________________________
Signature

Claim for Damage and/or Injury
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  Use this document to transmit your claim to your insurance agency.  Be complete; add any necessary and useful exhibits.  The more thorough you are the more apt you are to be believed and get prompt payment.

1. Make multiple copies.  Give one set to the insurance agency.  Keep a backup set (agencies are notorious for losing or misplacing paperwork).  Keep one set with the transaction file.
2. Remember that getting paid on a claim is a sales situation.  If they are “sold” on your credibility, they will generally pay promptly.  If not sold, it can be a long and ugly process.  As we have said before, you have one chance to make a good first impression.  Do your homework; get a complete and thorough file together; send it to them promptly.  All of this will increase the odds of a satisfactory result in your favor.