Damage Claim Form

Today's Date

Incident Date

Incident Time

Claimant Name

Claimant Address

Claimant Phone

Claimant Email

Make
Model
Year
Licensing State

Are you the property or vehicle owner?
If applicable, Claimant Vehicle Info:
Why do you believe it was our company?:
If applicable, please provide a description of our vehicle, Vehicle# or Plate#:

Exact location of the event: Street address (Nearest intersection, landmark, etc.):
Description of your damage (area & type):

What caused the damage? Where did it come from?

Witnesses
Name
Phone#:

Was a police report filed? If yes, what is the report#?
Road & weather conditions at time of incident:

*Please include any photos of the damage, police report or estimate/bill for repair*

Security Question:
What is the color of grass?

Please note- Submittal of a claim for damages does not guarantee payment by the company or its insurance carriers. An investigation by a claim adjuster will be made into the incident to determine if the company has any liability as determined by applicable laws.