PRELIMINARY AUTOMOTIVE CLAIM REPORT

PLEASE NOTE:

All claims should be reported to your broker as soon as possible after the loss. Your broker knows your policy and can answer your questions. All theft and vandalism claims must be reported to the Police.

For your convenience, you can print out the Automotive Claim Form and FAX it to your broker, or, to our office at 1-519-352-5344. OR You can also fill out the form below and submit it to us electronically. Please make sure to answer all sections that apply to your specific claim.

Date: *
Driver Name: *
Daytime Phone: *
Evening Phone: *
Address: *
Your Email: *
Vehicle: *
Date of Loss: *
Time of Loss: *
Was Anyone Hurt? List Names: *
Police:
Your Policy #: *
Broker: *
Other Driver Name:
Inusrance Company:
Policy #:
Details of Accident: *