Sterling & Serling: Secure Form

Automotive Claim

Date of Accident (mm/dd/yyyy)


Time of Accident
 am  pm
  Insured

Name:


Address:


City State ZIP
  Contact

Name:


Home Phone:
 

Business Phone:
 

Cell Phone:
 

Email:
  Loss

Location of Accident:


City State
Description of Accident:
  Insured Vehicle

Make:


Model:


Year:


Body Type:


VIN:


Plate Number:


Owners Name:


Owners Address:


City State ZIP

Phone:
 

Describe Damage:


Estimate Amount:


Where can vehicle be seen:
  Driver

Drivers Name:check if same as owner


Drivers Address:


City State ZIP

Phone:
 

Relation to Insured (Employee, Relative, Etc)


Date of Birth: (mm/dd/yyyy)


Driver's License Number
 State

Used with Permission?  Yes  No
  Property Damaged (Other Car)

Property Damaged (if auto year, make, model, plate #)


Other vehicle/property insured?  Yes  No

Company Name:


Policy #:


Owner's Name:


Owner's Address:


City State ZIP
Home Phone:
 

Business Phone:
 

Driver's Name:


Driver's Address:


City State ZIP
Home Phone:
 

Business Phone:
 

Describe Damage:


Estimate Amount:


Where can vehicle be seen:
  Witness or Passengers

Name:


Witness Address:


City State ZIP
Phone:
 

Remarks:


Reported by: