Claim Report Forms – Automobile | Zehr Insurance Brokers Ltd.

Claim Report Forms – Automobile

In an emergency claim situation, please contact our office directly.

*(denotes required field)

--- Policy Holder Information ---

Policy Number: *

Primary Contact Person: *

Home Phone: *

Work Phone: *

Where should we contact you?

Best time to contact you?

--- Accident Information ---

Who was driving?

Date of Loss or Accident:

Time of Accident:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

Is the vehicle drivable?

Yes No

If no, where can the vehicle be inspected?

Please provide as much detail as possible regarding the claim in the spece provided below. A reporesentative will contact you shortly. (Max 255 Words)

Did any injuries result from the Accident?

Yes No

If yes, please provide names, addresses, phone numbers and the extent of the injuries. (Max 255 Words)

--- Other Driver Information ---

Full Name:

Insurance Provider:

Policy Number:

Contact Phone: *

Licence Plate #:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

--- Location of Accident ---

City / Province:

Police Contacted? *

Yes No

Officer's Name:

Officer's Badge Number:

Report Number:

Were there witnesses? *

Yes No

First Name:

--- Witness #1 ---

Last Name:

Contact Phone:

Work Phone:

Email Address:

--- Witness #2 ---

First Name:

Last Name:

Contact Phone:

Work Phone:

Email Address:

Name of your broker:

CAPTCHA Code: *

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