Berends Hendricks Stuit Insurance Agency, Inc. ::: Auto Insurance Claim

Auto Insurance Claim

Please Note: You will need approval from your insurance carrier to begin repairs. If you have not been contacted within 48 hours, please call our office for assistance.

Policyholder Information

Name:

Date:

Phone: (no dashes)

Ext

Email:

General Information

Date of Loss:

Location of Loss:

Police:

Report Number:

Is Vehicle Drivable?

Describe What happened:

Injuries 1

Name:

Address:

Phone:

Where Taken:

Extent of Injuries:

Injuries 2

Name:

Address:

Phone:

Where Taken:

Extent of Injuries:

Injuries 3

Name:

Address:

Phone:

Where Taken:

Extent of Injuries:

Injuries 4

Name:

Address:

Phone:

Where Taken:

Extent of Injuries:

Insured Vehicle

Year, Make, and Model:

VIN:

Driver's Name:

Damage to vehicle:

Probable Amount of Loss:

Shop Name and Phone:

Other Party

Name:

Address:

City, State, Zip:

Home Phone:

Work Phone:

Property Damaged:

Insurance Information: