Insurance Claim Form
Claimant Information
Claimant name
*
First Name
Last Name
Claimant address
*
Address Line 1
Address Line 2
City
Postal Code
Telephone
*
(e.g. 519-234-5678)
Other phone
(e.g. 519-234-5678)
Email
(e.g. john@example.com)
Claim Information
Date of claim
*
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
Type of claim
*
Property damage
Loss of balance
Pot hole
Sewer Backup
Bus/Transit
Automobile accident
Other:
Location of claim
*
Description of claim
*
Damages suffered (estimates)
*
Have you received quotes/estimates for repairs?
*
Yes
No
Have you repaired and received a receipt for the repair?
*
Yes
No