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