Kent Essex Mutual Logo

KENT & ESSEX MUTUAL INSURANCE CO.
250 St. Clair St., Box 356,
Chatham, Ontario, N7M 5K4

Tel: (519) 352-3190  Fax: (519) 352-5344


1-800-265-5206

 HOURS: Mon - Fri: 8:30 am - 4:30 pm

PRELIMINARY
AUTOMOTIVE
CLAIM
REPORT

 Name of Driver:
  Date:
 Address:
  Daytime Phone:  Evening Phone:
 Vehicle:
  E-mail Address:
 Date of Loss:
 Time of Loss:		  Location:
 Was Anyone Hurt? Name: .
 Police:
  Policy #:
  Broker:
 Other Driver - Name:
 Insurance Company:
Policy #:
Details of the Accident:

   Signature:

For your convenience, you may fill out this form on your computer, print it out and fax it to us at 1-519-352-5344.