Berends, Hendricks, & Stuit Insurance Agency, Inc. :: Claims :: Personal Claims

Claims :: Personal Claims :: 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.

Contact Information
Name:
Date:
Daytime Phone Number:	Ext:
Email Address:

General Information
Date of Loss:
Location of Loss:
Police:
Report Number:
Describe What Happened:

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:
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