2 LOCATIONS
SERVING ALL OF
NORTHERN OHIO

CLEVELAND
28195 Settlers Reserve Way
Westlake, OH 44145
P: 216 221-1187
TF: 800-837-2699
F: 216-221-1191
Cell: 216 346 2548

Claim Form

This form is for use by insurance company representatives.
Required fields are marked with *

Insurance Rep Name: *
E-Mail: *
Insurance Company: *
Phone: *
Address:
City:
State:
Zip
Best time to call:

 

Claim #: Assigned To:
Time: Date:
Kind of Claim: Full Adj:
Company: Appraisal:
Agency: Policy #:
Exp. Date:  
Insured:
Address:
Phone (Res): Phone (Bus):
Contact/Driver:
Address:
Phone:
 
Coverage Auto: Property Loss Coverage:
B.I: A:
P.D: B:
COLL: C:
COMP: D:
M.P: E (BI):
U.M: F (MP):
Other: Other Ins:
Endorsements: Deductible:
  Endorsements:
  Co-Ins:
  Form #'s:
 
Vehicle:
Year: Make:
Model: Serial #:
Mortgagee:

Accident At:
Date: Time:
P.D. Owner: P.D. Driver:
Address: Address:
Phone: Phone:

Injuries:
 
Vehicle
Year:
Make:
Lic. #:
Vehicle at:


Description of Accident:
Police Report
To whom reported:
Witness Name:
Address:
Phone:

Suggested Reserves (If possible):
Notice Received by:

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